[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


    REUSABLE MEDICAL EQUIPMENT: CONTINUING TO EXAMINE VHA'S STERILE 
                          PROCESSING PROBLEMS

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      WEDNESDAY, SEPTEMBER 5, 2018

                               __________

                           Serial No. 115-74

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                    COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                    JACK BERGMAN, Michigan, Chairman

MIKE BOST, Illinois                  ANN MCLANE KUSTER, New Hampshire, 
BRUCE POLIQUIN, Maine                    Ranking Member
NEAL DUNN, Florida                   KATHLEEN RICE, New York
JODEY ARRINGTON, Texas               CONOR LAMB, Pennsylvania
JENNIFER GONZALEZ-COLON, Puerto 
    Rico

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           
                           C O N T E N T S

                              ----------                              

                      Wednesday, September 5, 2018

                                                                   Page

Reusable Medical Equipment: Continuing To Examine VHA's Sterile 
  Processing Problems............................................     1

                           OPENING STATEMENTS

Honorable Jack Bergman, Chairman.................................     1
Honorable Ann M. Kuster, Ranking Member..........................     3

                               WITNESSES

Teresa D. Boyd, D.O., Assistant Deputy Under Secretary for Health 
  for Clinical Operations, U.S. Department of Veterans Affairs...     5
    Prepared Statement...........................................    25

        Accompanied by:

    Beth Taylor, D.H.A., R.N., N.E.A.-B.C., Deputy Assistant 
        Deputy Under Secretary for Health for Clinical 
        Operations, U.S. Department of Veterans Affairs

Sharon Silas, Acting Director, Health Care, U.S. Government 
  Accountability Office..........................................     6
    Prepared Statement...........................................    27

John Daigh, M.D., Assistant Inspector General for Healthcare 
  Inspections, Office of Inspector General, U.S. Department of 
  Veterans Affairs...............................................     8
    Prepared Statement...........................................    32


 
    REUSABLE MEDICAL EQUIPMENT: CONTINUING TO EXAMINE VHA'S STERILE 
                          PROCESSING PROBLEMS

                              ----------                              


                      Wednesday, September 5, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                      Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Jack Bergman 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Bergman, Bost, Poliquin, Roe, 
Kuster, Peters, and Lamb.

          OPENING STATEMENT OF JACK BERGMAN, CHAIRMAN

    Mr. Bergman. Good morning. This hearing will come to order. 
I want to welcome everyone today as we discuss problems with 
the Veterans Health Administration sterile processing of 
reusable medical equipment, or RME.
    RME items such as endoscopes, forceps, and other surgical 
equipment is meant to be used repeatedly rather than discarded 
after a single use and, therefore, must be re-sterilized 
between uses to prevent infection. These re-sterilization 
practices, which fall largely under the jurisdiction of VA 
sterile processing services, or SPS, departments, must be both 
meticulous and timely to ensure that procedures occur safely 
and on schedule.
    Today, you will hear a lot of discussion about inspections 
and reports. In simplest terms, VA medical centers are required 
to conduct annual self-inspections on their SPS departments and 
report the findings to VHA. Additionally, VISNs are required to 
conduct annual inspections of SPS departments within their 
network and report the findings up to VHA central office.
    On top of that, VHA central office must conduct triennial 
inspections of each medical center SPS department. If followed, 
this oversight procedure would help ensure SPS departments are 
operated safely.
    Based on issues we uncovered regarding VHA's sterile 
processing services, we requested that GAO conduct an audit to 
identify any systemic shortcomings. Unfortunately, GAO found 
VHA's processes for ensuring the safety and consistent 
sterilization of RME to be sorely lacking.
    The findings in this report represent a collision of 
several issues this Committee has tracked throughout this 115th 
Congress. Of course the report describes ongoing issues with 
sterile processing and workforce management, two challenges 
that the VA routinely battles. But an examination of root 
causes reveals another familiar theme: breakdowns in enterprise 
governance, particularly at the network and central office 
level. These create the opportunity for failures in safety 
protocols to go unnoticed or uncorrected.
    It is troubling to learn that VISNs were not consistently 
conducting annual inspections of their medical centers' SPS 
departments, meaning that networks don't know if their medical 
centers are training their employees, conducting quality 
checks, or otherwise running their sterile processing 
departments in an appropriate manner.
    But what is equally concerning is the fact that VHA's 
central office apparently had no idea that some VISNs were 
failing to submit SPS inspection reports to central office, 
suggesting that blame goes all the way to the top. 
Specifically, GAO's report explains how VHA officials were not 
even aware that they had not received all of these inspection 
reports until we requested this audit and GAO started asking 
questions.
    To explain a little further, GAO found that over one-
quarter of the expected 144 reports were never submitted. In 
some of these cases, GAO found that networks had conducted 
reviews but just never bothered to submit reports to VHA 
central office. When one network office was asked why they 
failed to turn in reports, they told GAO that they ``see no 
value in submitting them''.
    To that point, VHA officials admitted that they seldom 
share information like SPS trends or best practices with the 
field, leaving medical centers and networks unaware of how they 
compare to other programs and in what areas there is room for 
them to improve. If VHA pays this information little attention 
and the field has no access to it, then clearly the established 
mechanisms for collecting and disseminating data fail to serve 
VA employees or, most importantly, veterans. The current 
governance structure is simply not getting the job done.
    The Committee has raised this issue several times this 
year, including an entire hearing dedicated to VHA governance 
in general and the role of VISNs in particular. Central to that 
hearing and to this one today is the hospital that became the 
poster child for many of these issues, the Washington, D.C., 
Medical Center.
    Since the OIG's reports in our May hearing, we found out 
last month that the D.C. VA Medical Center performed so poorly 
this past quarter that its status has been downgraded from 
``high-risk'' to ``critical.'' So VHA'S central office will 
become even more hands-on in their attempt to rehabilitate the 
hospital. It is also still without a permanent director.
    The SPS issues we will discuss today are the tip of an 
expansive iceberg of governance issues continuing to prevent VA 
medical centers from consistently delivering high-quality 
health care in a timely manner. I look forward today to not 
only discussing solutions to RME-related issues but also 
continuing our conversation regarding the broader root problems 
that continue to dog the system as a whole.
    With that, I yield to Ranking Member Kuster for any 
introductory comments she may have.

       OPENING STATEMENT OF ANN M. KUSTER, RANKING MEMBER

    Ms. Kuster. Thank you, Chairman Bergman, for holding this 
hearing, and thank you to our witnesses on the panel, 
particularly GAO and IG, who continue to investigate and study 
sterile processing of medical equipment and medical supply 
chain concerns. It is important that these vital functions 
succeed, because their failure, as we now know from too many 
incidents, put patients at risk of harm.
    The results of GAO's latest report are troubling. Not only 
did GAO find that the VA lacked reasonable assurance its 
medical centers were following policies intended to provide 
clean, reusable medical equipment but that these recent 
findings were similar to those reported in 2011.
    Worse, the IG found these same problems at the D.C. VA 
Medical Center, as referenced by the chair. And for those of 
you familiar with the many problems reported by the 
whistleblowers at Manchester, New Hampshire, VA Medical Center, 
sterilization and facility maintenance issues contributed to 
patient-access and quality-of-care problems there as well.
    This continued pattern of lax oversight and accountability 
over basic functions of a modern hospital is indicative of a 
systemic problem with the VHA, a problem that justifies VHA's 
listing as an agency of high risk. The sad reality is that the 
VA has been on GAO's high-risk list for years, and yet still 
the VA has failed to provide an action plan to improve 
operations, nor has VA made significant progress in making 
obvious corrections to its poorly heeded internal controls.
    GAO's report found 27 percent of inspections of the sterile 
processing services at VA medical facilities were not even 
reported to the national sterile processing office in VA's 
central office or that the central office does not communicate 
inspection results to the VISNs or VA medical facilities so 
that they could address common deficiencies. Without this data, 
VA cannot know which of their facilities are experiencing 
problems to prevent incidents like those at the Manchester, New 
Hampshire, VA.
    GAO found that VA has yet to study its nationwide workforce 
shortage within sterile processing services so that it can 
determine why some facilities are experiencing major problems 
due to understaffing.
    GAO found that facility infrastructure problems, especially 
in older facilities, were leading to inspection deficiencies, 
but it is unknown whether VA has the resources, let alone even 
a plan, or if they are working on a plan to address these 
issues.
    And I hope we will hear from you on that today.
    In May, this Committee held a hearing that investigated a 
related issue, the failed implementation of the real-time 
locating system, RTLS, a failure that contributed to problems 
at D.C. and a system intended to help manage and provide 
oversight and accountability of sterilization.
    I am disappointed to see that VA's written testimony lacks 
a progress report on this half-billion-dollar system that is 
years overdue. And, again, I hope that you will provide this 
Committee with an update.
    Underlying all of these findings is a lack of planning, 
resources, and especially leadership throughout VHA to use the 
information it receives in inspections to correct deficiencies, 
identify issues, and, as the chair mentioned, disseminate best 
practices so that other medical facilities can take action. VHA 
must ensure that there is an adequate workforce to clean and 
process increasingly complex reusable medical equipment.
    To its credit, GAO found that the VA has the organizational 
structure and processes in place to ensure medical equipment is 
sterilized and processed accordingly. And we also know that 
providers, such as the doctors and nurses and frontline health 
care staff who care for our veterans, have often gone above and 
beyond to overcome supply-chain failures and that lack of 
leadership so that veterans will receive quality care.
    The importance of good leadership and the willingness to 
reform processes at the facility level is crucial for VA 
successes. I am pleased to report that, after new leadership 
was installed at the Manchester facility, they acted to resolve 
issues around sterile processing.
    Recent reviews by the joint commission have identified 
their reformed practices and procedures as a, quote/unquote, 
best practice that the VA should use nationally. And I would 
invite the VA to come up and meet with Mr. Al Montoya and to 
review what changes were made. These are the actions the VA 
needs, and I hope the VA can take the initiative and 
disseminate these practices across the country.
    What the VA needs, once again, is good leaders and 
sufficient resources to ensure that processes are followed so 
that our veterans receive the highest-quality and timely care. 
I hope from this hearing we can get a commitment from the VA to 
devote resources to staff and facility infrastructure to 
address logistics and sterile processing challenges and to 
ensure that every VA facility inspection leads to corrective 
action to address issues threatening the health and well-being 
of our veterans.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Bergman. Thank you, Ranking Member Kuster.
    I now welcome the members of our first and only panel, who 
are seated at the witness table. With us today from VA, we have 
Dr. Teresa Boyd, Assistant Deputy Under Secretary for Health 
for Clinical Operations. She is accompanied by Dr. Beth Taylor, 
Deputy Assistant Deputy Under Secretary for Health for Clinical 
Operations.
    Also on the panel we have Ms. Sharon Silas, Acting Director 
of the Health Care Team for the Government Accountability 
Office. Finally, from the VA Office of Inspector General, we 
have Dr. John Daigh, the Assistant Inspector General for 
Healthcare Inspections.
    I ask the witnesses to please stand and raise your right 
hand.
    [Witnesses sworn.]
    Mr. Bergman. And let the record reflect that all witnesses 
have answered in the affirmative.
    Dr. Boyd, you are now recognized for 5 minutes.

                  STATEMENT OF TERESA D. BOYD

    Dr. Boyd. Thank you. Good morning, Chairman Bergman, 
Ranking Member Kuster, and Members of the Subcommittee. I 
appreciate this opportunity to discuss the Department of 
Veterans Affairs sterile processing services programs with 
respect to reusable medical equipment, or RME.
    I am accompanied today by Dr. Beth Taylor, Deputy Assistant 
Deputy Under Secretary for Health for Clinical Operations and a 
former chief nurse executive with oversight responsibilities of 
SPS at a VA medical center.
    VHA operates one of the largest health care delivery 
systems in the Nation, serving over 9 million veterans, one of 
whom is my stepson, who recently transitioned from Active Duty 
Navy.
    In providing health care services to veterans, VA medical 
centers use RME, which must be reprocessed between uses. Due to 
the increasing complexity of design and components, 
reprocessing has become much more complicated and time-
consuming. Improper reprocessing creates potential risks, such 
as infection, and can adversely affect timely access to care, 
such as delayed or canceled surgeries due to the lack of 
properly reprocessed RME.
    Understanding that a successful SPS program involves many 
services at a facility, a group of stakeholders came together 
earlier this year to address the top trended challenges 
reported in our SPS programs. These challenges were identified 
through internal audits at all levels of the organization as 
well as via issue briefs, an internal communication that I have 
come to embrace and welcome.
    We identified four major areas to work on: workforce, 
including conversion of the sterile processing occupation to 
Title 38 hybrid; streamlining contracting and procurement 
processes; improvement of reporting and auditing; and 
addressing repairs and coordination of such within our aging 
infrastructures.
    SPS is dedicated to sustainable corrective actions and is 
achieved through improved communication, focused education and 
training, as well as commitment to collaborative policy changes 
with key stakeholders.
    In the GAO draft report issued in June 2018, there were 
three recommendations to the Under Secretary for Health, which 
are detailed in my written testimony, all of which VHA fully 
concurs with. We appreciate the GAO report and found it 
validating, as their recommendations correspond with our 
aggressive actions undertaken prior to the draft report. We are 
strongly committed to developing long-term solutions that 
mitigate risk and improve quality and safety of the VA health 
care system.
    Central to the success of SPS operations in the field is a 
solid and strong workforce. It is imperative that we have not 
only trained and experienced frontline staff but also solid 
leadership in every SPS program. We know all too well the risk 
that leadership turnover poses on any program, including the 
oversight and management of this very complex and vital one. 
And we continue to address the need to not only hire and train 
frontline staff but retain them.
    SPS programs have significantly improved the efficiency and 
safety of health care of our veterans, as well as non-veterans, 
as exemplified in recent cases of factory vendor deficits noted 
by VA staff and who are now working with industry for universal 
changes.
    Patient safety and infection control will be improved 
because surgical instruments are being reprocessed correctly. 
As a physician, as a VA leader, and as the mother of a Navy 
veteran who receives his care at the D.C. VA Medical Center, I 
am confident in our ability as a learning organization to 
become one of high reliability.
    To sustain these efforts, we look forward to working with 
Congress, the GAO, and OIG as we collaborate to modernize VA. 
It is critical that we continue this current momentum and 
preserve the gains made thus far. Congressional support is 
essential to providing care for veterans and their families and 
is greatly appreciated.
    Mr. Chairman, this concludes my testimony. My colleague and 
I are prepared to answer any questions.

    [The prepared statement of Teresa D. Boyd appears in the 
Appendix]

    Mr. Bergman. Thank you, Dr. Boyd.
    Ms. Silas, you are now recognized for 5 minutes.

                   STATEMENT OF SHARON SILAS

    Ms. Silas. Thank you. Chairman Bergman, Ranking Member 
Kuster, and Members of the Subcommittee, thank you for the 
opportunity to be here today to discuss a recently issued 
report on the oversight of VA medical centers' processing of 
reusable medical equipment.
    The VA has a responsibility to ensure that veterans are 
receiving safe and timely access to care. Improper processing 
of reusable medical equipment could pose extreme risk to 
veterans' health, potentially exposing patients to infection or 
leading delays in care if equipment are not readily available 
for medical procedures.
    VA medical centers use reusable medical equipment for a 
variety of procedures. This type of equipment can be used 
daily, often multiple times, and range from simple medical 
instruments such as surgical scalpels to more complex medical 
devices such as camera-bearing endoscopes.
    Historically, the Veterans Health Administration has 
encountered problems ensuring that medical equipment has been 
properly processed. For example, in 2009, the VA notified 
nearly 10,000 veterans that they may have been exposed to 
various infections due to endoscopes that were improperly 
processed at VA medical centers.
    Since then, both GAO and the VA OIG have reported numerous 
times on these challenges, highlighting the need for better 
sterile processing practices and guidance and more effective 
training for VA's sterile processing staff.
    The Veterans Health Administration has tools to help ensure 
medical centers adhere to policies and requirements. For 
example, each year, VA's regional offices, or VISNs, use a 
standardized inspection checklist to review medical centers' 
sterile processing programs. There are also issue briefs 
generated when a medical center is involved in a significant 
safety incident that affects a group or a cohort of veterans.
    We examined the Veterans Health Administration's oversight 
of VA medical centers' processing of reusable medical equipment 
and found that the VA central office did not have complete 
information on the VISN inspections of the medical centers' 
sterile processing departments, departments which are 
responsible for managing and conducting the processing of 
reusable medical equipment.
    Specifically, we found that for 144 VISN inspections that 
were supposed to have been conducted in fiscal year 2017 the 
central office was missing 39 inspection reports. Further, we 
learned that, in some instances, some of these inspections were 
not conducted at all.
    We also found that the central office does not analyze or 
share information on inspection results across the VA health 
care system due to a lack of resources. As a result, VA is 
missing out on an opportunity to share lessons learned and best 
practices that could help mitigate potential problems across 
the VA health care system. And, in fact, VA medical center 
staff we spoke with told us they would like information on 
inspection outcomes and trends and findings so they can better 
address processing challenges.
    Lastly, we identified areas where VA medical centers were 
experiencing challenges in processing reusable medical 
equipment. For example, sterile processing departments 
experienced challenges hiring and retaining qualified staff to 
properly manage and handle the processing of reusable medical 
equipment. These departments, like many others across VA, 
typically experience long timeframes to hire qualified staff. 
We also heard that staff typically receive low pay and, once on 
board, often have to work overtime and have limited 
opportunities for job growth.
    Particularly as medical equipment continues to evolve and 
become more complex, it is even more important that VA has 
enough highly trained staff to process reusable medical 
equipment.
    Based on our findings, we recommended that VA should ensure 
that the annual VISN inspections of VA medical centers' sterile 
processing programs are conducted, and the findings reported to 
the central office and that the results of these inspections be 
shared across the VA health care system to help all programs 
improve. Lastly, VA should study sterile processing workforce 
needs to ensure medical centers have enough qualified staff to 
effectively reprocess medical equipment.
    In short, although the Veterans Health Administration has 
taken steps in the last few years to improve their oversight of 
reusable medical equipment, such as developing new guidance and 
policies, we found there are still some areas of improvement 
needed to ensure veterans continue to receive safe and timely 
access to health care.
    This concludes my opening remarks. Thank you.

    [The prepared statement of Sharon Silas appears in the 
Appendix]

    Mr. Bergman. Thank you, Ms. Silas.
    Dr. Daigh, you are now recognized for 5 minutes.

                 TESTIMONY OF JOHN DAIGH, M.D.

    Dr. Daigh. Thank you, Chairman Bergman, Ranking Member 
Kuster, Chairman Roe, Members of the Committee, it's an honor 
to be asked to testify before this Committee today.
    I think it's fairly straightforward to understand the 
functions of sterile processing, logistics, and human resources 
at a VA hospital. The OIG report on critical deficiencies at 
the D.C. VA highlights the fact that the risk of clinical error 
and, therefore, harm to patients increases when these business 
functions do not operate successfully. In addition, the poor 
performance by these functions increases the cost of VA health 
care.
    The OIG reports and the current GAO report identify VA's 
organizational structure, in my view, as an impediment to the 
efficient operation of these business functions by presenting 
confusing lines of authority. The current administrative 
alignment of VA, in my view, is outdated. It was created before 
the widespread use of email, before the prevalence of large 
data systems. And it is, I think, time to consider changes to 
the organizational structure of VHA's VISN system.
    With respect to SPS controls, VA currently places too much 
risk-prevention strategy upon the shoulders of the bedside 
clinician to recognize and react to problems when the equipment 
they are provided may in some way be defective--that is, at the 
point of care.
    Having said that, this conversation is mostly about the 
risk of harm to veterans. I am not infrequently called and 
asked to comment on why a facility closed their operating room 
or chose to limit certain procedures, and when I call VHA 
leadership, invariably I get a wonderfully responsive, 
appropriate answer indicating that there was found some defect 
in SPS processing or other defect, and they've taken the exact 
correct step in the interest to not harm veterans.
    I would be pleased to answer any of your questions. Thank 
you.

    [The prepared statement of John Daigh appears in the 
Appendix]

    Mr. Bergman. Thank you, Dr. Daigh.
    I now yield to Ranking Member Kuster. Do you want to go 
ahead and do your questions first?
    Ms. Kuster. I would be happy to.
    Mr. Bergman. All right.
    Ms. Kuster. Thank you very much. Thank you, Mr. Chairman.
    And thank you to our panel for being with us today.
    I wanted to focus in, and hopefully our VA witness will 
have a plan in place about this, but what is being done to hold 
senior leaders at VA medical facilities, VISNs, and VHA 
accountable for the management failures within the facilities' 
sterile processing services? And is there a plan for 
improvement and particularly for sharing best practices?
    Dr. Boyd. So the first question, about accountability, this 
came up in multiple conversations, as I mentioned earlier, when 
a group got together in looking at the world of SPS and the 
failures and the weaknesses and gaps that we needed to address. 
And you mentioned, I think, earlier as well about VHA 
governance and some of the modernization as well.
    What we found is that--and there's no excuse for it--there 
have not been very codified, clear roles and responsibilities 
at all levels of the organization. Coming in new to this role, 
as many of us did, and coming from the field, this is an 
improvement that must occur. So we are working on those roles 
and responsibilities at all levels, so everybody knows what the 
expectation is, what they're accountable for.
    And this goes all the way down to the chief nurse exec 
within a facility, who actually reports and works hand-in-hand 
with the medical center director, all the way on up through the 
VISN, with a quality management or the chief nurse at a VISN 
level, all the way on up to my level as well.
    Ms. Kuster. Do you agree that, for example, in Manchester, 
New Hampshire, surgeries had to be stopped because there was--
the quote that I read--rust or blood on the surgical 
instruments? Does that threaten the quality of care for 
veterans and even access to care if surgeries have to be 
canceled?
    Dr. Boyd. So, twofold. It's important that we, like Dr. 
Daigh mentioned, actually welcome staff stopping the line when 
they find things like that. Now, that being said, if there is a 
trend on that, if it's not a one-off, then we need to, you 
know, really look, you know, further and deeper and move it to 
the left and say, what happened along the way that we're 
getting this?
    Ms. Kuster. Well, even if it's a one-off, what's the 
process? Is there an investigation when that happens?
    And, I mean, I guess what I want to hear from you is some 
urgency in tackling this. Because another example, there were 
10,000 veterans notified of potential hepatitis infection. I 
mean, this seems, to me, urgent in terms of our interest in 
caring for our veterans.
    Dr. Boyd. So you mentioned the 10,000 back in 2009. There 
was a tremendous sense of urgency at that point, and that's 
when SPS changed from purely an administrative, non-clinical, 
logistics-type function in a program very rapidly into a 
clinical--under the clinical nurse exec at the field. And 
that's when we realized we needed SOPs, standard operating 
procedures, in place, manufacturer instructions and to use 
those.
    And so there was a huge sense of urgency back in 2009. I 
hope--
    Ms. Kuster. Do you feel like that's lost now?
    Dr. Boyd. I do not feel that that's lost, Ranking Member 
Kuster.
    What we have in place, though--what we're finding now are, 
I would hope, the one-off. And if it's a one-off, it's still a 
problem. We need to stop and figure out what happened along the 
way. Was there a competency issue? Were the SOPs not in place 
for that particular frontline staff member? All along the way, 
we need to figure that out.
    Because you're absolutely right--
    Ms. Kuster. It seems like there's also a lack of staff, 
there's a shortage of staff, and that there's a long wait time 
to hire staff. Is anything being done to focus on that problem?
    I understand they enter as a GSA-5. That probably isn't 
drawing the quality of the--
    Dr. Boyd. Right.
    Ms. Kuster [continued].--staff that you need in these 
roles.
    Dr. Boyd. You're absolutely correct. And one of the major 
changes that has recently occurred is that we finally have 
changed the occupation series from a strict Title 5 to a Title 
38 hybrid, which gives us pay flexibility. It will also--this 
is fairly new, so we finally got that. And so this will change 
the grades as well.
    Now, that's not everything. You know, we still have the 
assistant chief and chiefs with which to deal with. But it does 
address our authorities at the front line for these folks. 
You're absolutely right.
    Ms. Kuster. So my time is up. I yield back.
    Mr. Bergman. Thank you.
    Chairman Roe, you are recognized for 5 minutes, sir.
    Mr. Roe. Thank you, Mr. Chairman.
    And I want to say that I find it amazing that we're even 
having this meeting today. I mean, it's astonishing to me.
    Koch's postulates, which the three of you, I know for sure, 
know what that is, is a German theory of disease published by 
Dr. Koch in 1890. So we've known what that is. The most basic 
function that's performed in a hospital--and I know the three 
of you all have been in operating rooms, in patients' rooms--is 
to make sure that you have sterile equipment in which to 
operate and take care of those patients. That is the most basic 
thing we do in a hospital.
    And I find it absolutely amazing that we're having this 
hearing this morning, that we're even talking about it. Because 
I know, when I went in the operating room--I've been there 
thousands of times, as a primary surgeon, as an assistant 
surgeon, as a medical student, as a resident, and then as a 
professor teaching residents how to operate--I never even 
thought about was the equipment going to be sterile that I'm 
using today. Every day, before I went in the operating room, 
somebody from the surgical suite would come in and say, ``Dr. 
Roe, you're doing this tomorrow. We have your sutures pulled. 
We have all the equipment you need to do your surgery.'' I 
don't ever recall a case that was canceled because the 
equipment wasn't sterilized properly.
    If you're in a for-profit hospital system, as many people 
have here, that information got out, that thousands of people 
potentially were harmed because of that, that hospital system 
probably would cease to exist because of lawsuits.
    And, I mean, I still cannot imagine that we don't have 
procedures, very basically, about how we train people to 
sterilize equipment. I find it amazing.
    This is my 10th year here. If I'm fortunate enough and come 
back, am I going to continue to see stories in the paper about 
we haven't gotten--someone's going to the operating--because, I 
mean, your stepson may be going into the operating room. And I 
would want to think that that young man would confidently go 
there, thinking, ``I'm at a VA hospital and I'll be cared for 
properly here and that the equipment is sterilized.'' Can he go 
there with that assurance?
    That's my question. Can he?
    Dr. Boyd. I believe he can. And here is--
    Mr. Roe. Well, believing is different than knowing that he 
can. I want to know that he can go there and that the surgeons 
know that the equipment is sterile and that they can 
confidently know that when they take he or she veteran to the 
operating room or to wherever, to any procedure room, that that 
equipment will be functioning and it will be sterile and that I 
don't have to even worry about that.
    Dr. Boyd. That's correct.
    And what I can say to that is this. When you look at 
surgical site infections--because I think that's a surrogate 
marker for poor or inadequate operative arenas--the surgical 
site infection rate at the D.C. VA is 1.09 percent. The 
national rate is 1.41 percent. And the most recent industry 
data is 1.9 percent. And this is in the operatories; it's the 
surgical site infection rate.
    I can also say that because of our culture of safety and 
our transparency, which we absolutely stress--
    Mr. Roe. Let me back up.
    Dr. Boyd. Okay.
    Mr. Roe. And we can argue about those things. The question 
I have--and, obviously, if you're in a trauma center, your 
infection rate is going to be higher than if you're doing all 
elective surgeries.
    Dr. Boyd. That's true.
    Mr. Roe. You've got to compare apples to apples. If you're 
doing sterile gallbladder laparoscopic cholecystectomies, that 
infection rate ought to be minimal. If you're doing gunshot 
wounds and trauma, open fractures, you're going to have a 
higher infection rate. So you've got to know what you're 
comparing to.
    Dr. Boyd. Absolutely, sir, yes.
    Back to your question, though, of the operations that we 
had on the books that were scheduled and that we actually 
performed in the VA in the past year, we had over 424,000 
surgeries performed, and our cancellation rate was only 0.8 
percent that was attributed to RME issues. And our staff report 
very quickly, which is a good thing, that they stop the line if 
there is an issue. So 0.8 percent of those cases were canceled 
due to RME.
    Mr. Roe. Let me ask you very quickly, and I know my time is 
about expired, but, basically, Dr. Boyd, what are you doing to 
address the key oversight breakdowns in the National Program 
Office for Sterile Processing?
    And then why were these issues not addressed after the 2011 
GAO report and the IG report on the Washington, D.C., VA? And 
I'll leave that for later if we have a second round.
    I yield back.
    Mr. Bergman. Thank you.
    Mr. Peters, you're recognized for 5 minutes.
    Mr. Peters. Thank you, Mr. Chairman.
    And thanks to the witnesses for being here.
    I did know that in San Diego that there's been a recent 
renovation of the sterile processing services facilities. But 
there's this issue that I think GAO, Ms. Silas identified with 
respect to personnel. They have found that the SPS technician 
position was downgraded by the VA's classification unit. The 
local facility can't change the classification of that 
position. And then, as I think was mentioned, the hiring 
process is 3 to 4 months long. There's long hours, limited pay, 
limited promotion.
    So what, programmatically, is going to be the VA's response 
to this? Are we going to talk about changing the classification 
of the position? What would we do to make sure we get the right 
people taking care of this important task?
    Ms. Taylor. I think there's a couple things in response to 
your question. One, that it's going to be one of our top 
priorities to address the workforce issues. Because you're 
absolutely right; these are key to the success of any well-
staffed, well-run SPS program.
    The downgrades occurred with regards to the SPS leadership 
roles, the chief and the assistant chief, not to the 
technicians.
    So we did have published guidance this summer that came out 
that transitioned them from a pure Title 5 to a hybrid 38, 
which Dr. Boyd mentioned. That we consider as step one.
    Step two is moving forward to look at those classifications 
of our leadership roles and ensure we have the right 
classifications, the right salaries to attract the quality and 
the skill sets required to run this very complex service.
    Mr. Peters. So, Dr. Taylor, do you disagree with any of the 
things that Ms. Silas mentioned about the difficulty in hiring 
the right kind of employees? Do you generally agree with that?
    Ms. Taylor. I generally agree, yes, sir.
    Mr. Peters. So you've talked about one reclassification--I 
think that's what you said just now--that you did?
    Ms. Taylor. The classification of the SPS service, the 
downgrade was focused on the chief and assistant chief.
    Mr. Peters. Right.
    Ms. Taylor. So that's going to be our priority going 
forward, is getting those classified at the level we think is 
commensurate to attract and retain the quality and skill set we 
need.
    Mr. Peters. And have you made any specific conclusions 
about what you need to do to address this in terms of the level 
of salary or--
    Ms. Taylor. Yes. We have a workforce work group, actually, 
that has convened, started the work earlier this summer. We're 
requesting that they provide a do-out by the end of December of 
this calendar year focusing on that exact issue, sir.
    Mr. Peters. Okay. So, to me, that seems like a lot of time 
for a pretty specific question that's been raised about, you 
know, one workplace employee. So I am disappointed to hear it's 
December.
    But when do you anticipate you're going to make a 
recommendation on actually changing the conditions or the 
turnaround or the salaries so that we know we get the right 
people in these jobs?
    Ms. Taylor. You know, I think it's important for me to 
share that in the interim we're also looking at the application 
of the pay authorities that we currently have and ensuring that 
the medical centers who have challenges or are in markets such 
as San Diego and greater Los Angeles, et cetera, that they're 
using those authorities in a way that they can retain the 
staff.
    For example, you know, retention bonuses that were just 
implemented in greater Los Angeles for the technicians, not the 
chief or assistant chief but at the technician level, to make 
sure that we could retain those individuals.
    So that's really a priority for us, to dialogue with the 
human resource officers at the VISN and the local levels 
between now and the end of the year to ensure that we're using 
the authorities we have most--
    Mr. Peters. So you're looking at the employment market VISN 
by VISN, so that's why it takes more time. Is that what you're 
saying?
    Ms. Taylor. That's correct. The employment market in 
greater Los Angeles is different than the employment market in 
Grand Junction, Colorado, for example.
    Mr. Peters. Right. Okay.
    And then after you get the report in December, do you have 
a sense for how long it will take you to make a recommendation? 
It doesn't seem like a very complicated thing to me.
    Ms. Taylor. I think we should have recommendations within 
the next 6 months.
    Mr. Peters. All right. Good. Well, I'll look forward to 
seeing you back at the Committee--
    Ms. Taylor. Yes, sir.
    Mr. Peters [continued].--or if the Chairman wants to 
entertain it in writing, whatever, we'd be happy to hear what 
you do about this.
    Obviously, it's fun to hear Dr. Roe talk about how basic 
this is. I think a lot of us lay people who are customers in 
hospitals, we worry about infections these days. And, you know, 
we know that the kinds of infections that we're susceptible to 
in hospitals are particularly pernicious. So I think it's 
certainly important for us to get in charge of this, and hope 
you take that seriously.
    Ms. Taylor. Absolutely.
    Mr. Peters. Thank you, Mr. Chairman. I yield back.
    Mr. Bergman. Thank you, Mr. Peters.
    Mr. Poliquin, you're recognized for 5 minutes.
    Mr. Poliquin. Thank you, Mr. Chairman, very much. I 
appreciate it.
    Ms. Silas, you're involved with the GOA, right? GAO. 
Whatever it is. I know what you folks do, generally speaking.
    Every 3 years, the VA central here in D.C. is supposed to 
make sure that 150 or 160 different VA hospitals around the 
country submit a report such that the VA central is comfortable 
knowing that the hospitals in the field follow a procedure to 
make sure things are sterilized when they operate on our 
veterans. Is that right? Yes or no?
    Ms. Silas. Well, there are actually a number of oversight 
tools that--
    Mr. Poliquin. Is VA central due to investigate these folks 
every 3 years? Yes or no?
    Ms. Silas. The VISN inspections happen annually.
    Mr. Poliquin. Well, I was going there next, is that we have 
18 VISNs, which are the regional folks, right?
    Ms. Silas. Uh-huh.
    Mr. Poliquin. Not VA central here in D.C., but the regional 
folks. And they're supposed to get annual reports from the 
hospitals out there. Is that right?
    Ms. Silas. Yes.
    Mr. Poliquin. Okay. But, if I understand this correctly, in 
2017, 27 percent of the hospitals didn't even submit a report 
that they followed these protocols to make sure this equipment 
is sterile. Is that correct?
    Ms. Silas. It was actually 27 reports had been submitted.
    Mr. Poliquin. Okay. A bunch have not been, right?
    Ms. Silas. Yes.
    Mr. Poliquin. Okay. And then those that were submitted, I 
think anywhere from 20 to 40 percent did not adhere to the 
procedures that were outlined to keep this equipment sterile. 
Is that right?
    Ms. Silas. Those were the 27--
    Mr. Poliquin. Okay. I just heard--thank you.
    I just heard from Ms. Boyd, I think it was, that--and read 
somewhere, also, that VA central doesn't have enough resources 
to make this happen. Doesn't have enough resources.
    Let me remind everybody here that 10 years ago the VA 
system had 230,000 employees. They now have 385,000 employees. 
And over the last 8 years, the budget's gone from roughly $80 
billion or $90 billion to $187 billion per year.
    You think you can find someone there to do this right?
    How long has this been going--Ms. Boyd, how long has this 
been going on? How long have we had a problem with making sure 
this equipment is sterile, which is so commonsense, so our 
veterans, who gave us our freedom, gave us our country, aren't 
impaired? How long has this been going on?
    Dr. Boyd. So, if I could just make one just real 
clarification here--
    Mr. Poliquin. Sure.
    Dr. Boyd [continued].--the reports that get rolled up, the 
audits and the oversight, the site visits that occur from a 
VISN into a facility and then also our triennials, there are 
160 some-odd checkpoints on there. And it's everything from 
documentation of competencies to--
    Mr. Poliquin. Yep.
    Dr. Boyd [continued].--the humidity, I mean, all sorts of 
things.
    Mr. Poliquin. Yep.
    Dr. Boyd. So, not clearly that they're just not following--
they're not ending up with safe equipment.
    Mr. Poliquin. Yeah, I know. That was one of the things you 
folks said, that the clinics are so unique that a standard 
protocol doesn't fit every site.
    Doctor, do you believe that?
    Dr. Daigh. I think the standard protocols would apply to a 
piece of equipment across each site.
    Mr. Poliquin. Yeah, I would think so too.
    Could you answer my question, Ms. Boyd, that I asked a 
minute ago? How long has this been going on? How long have you 
had a problem with this?
    Dr. Boyd. Your question, again, was how long have we had a 
problem with maintaining oversight?
    Mr. Poliquin. No, making sure that the equipment is sterile 
at the hospitals such that our veterans are cared for properly, 
which means they've got to follow a procedure, right, that's 
dictated from central or from the VISNs, and they clearly 
aren't doing that. How long has this been going on, all of it?
    Dr. Boyd. Okay. So we still have--
    Mr. Poliquin. A year? Two years? Ten years? As long as 
you've been there? How long?
    Dr. Boyd. We do have opportunities to improve our--
    Mr. Poliquin. Who is--forget the question, because you're 
not going to answer it?
    Who is responsible--who is responsible at--I want the head 
person who is responsible at VA central to make sure this 
equipment is sterile and folks in the field are following the 
protocols? Who is responsible? I want a name. Who is it, 
please?
    Ms. Taylor. We are, sir.
    Mr. Poliquin. You are. Good.
    You too?
    Dr. Boyd. Uh-huh. Yes, sir.
    Mr. Poliquin. Wonderful. How long have you been there, each 
of you?
    Ms. Taylor. I came in April, sir.
    Mr. Poliquin. April of this year?
    Ms. Taylor. Yes, sir.
    Mr. Poliquin. And how long have you been there, Ms. Boyd?
    Dr. Boyd. And I came in May.
    Mr. Poliquin. In May. So you're new. So I can't point 
fingers at you because you're trying to fix the problem, right?
    Dr. Boyd. Yes, sir. And we both came from the field.
    Mr. Poliquin. Great. Thank you very much. So I won't lose 
my patience with you.
    Is this getting better, or are you going to come before us 
a year from now and say, ``We have the same problems,'' and 
these nice folks over at the GAO and over at Inspector General 
are going to say, ``No, they talked about it, they haven't 
fixed it''? Are you going to fix this or not?
    Dr. Boyd. I would like to answer that. Yes--
    Mr. Poliquin. Take your time.
    Dr. Boyd [continued].--sir.
    Mr. Poliquin. Good. When?
    Dr. Boyd. Yes, sir. We will be glad to come back here at 
the request of the Chairman at any time and give you an update.
    Mr. Poliquin. Thank you.
    Dr. Boyd. We have multiple work groups, we have multiple 
actions in place, thanks to the oversight that we get from OIG 
and GAO. They are our partners.
    Mr. Poliquin. Before you came here, Ms. Boyd, who was 
responsible for this? Before you and Ms. Taylor came here.
    Dr. Boyd. So the person in this role prior was Dr. Lynch.
    Mr. Poliquin. Was Dr. Lynch. Is he still at the VA?
    Dr. Boyd. No, sir. He is retired.
    Mr. Poliquin. He's retired. Anybody else involved? Or just 
Dr. Lynch, he was the person?
    Dr. Boyd. In the role that I--I took over in that role.
    Mr. Poliquin. Did he retire, or was he asked to leave?
    Dr. Boyd. Oh, he retired.
    Mr. Poliquin. He retired. Okay.
    Dr. Boyd. Yes, sir.
    Mr. Poliquin. Keep doing what you're doing. We'll help you 
every way we can. Thank you very much.
    Dr. Boyd. Thank you.
    Ms. Taylor. Appreciate that.
    Mr. Poliquin. Thank you, Mr. Chairman.
    Mr. Bergman. Thank you, Mr. Poliquin.
    By the way, we will have a second round. So, you know, for 
those--because I think we may have some more questions, 
especially given the knowledge base of our panel here.
    So, Mr. Lamb, you're recognized for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman.
    Ms. Boyd, Ms. Taylor, I just want to ask about an incident 
at the Clarksburg VA in West Virginia involving spotting on 
some of the surgical instruments. Are you familiar with that 
episode? It happened in the last few years.
    Yeah. So, when that happened, some of the veterans who were 
affected by it, in terms of their appointments and procedures, 
were sent up to the Pittsburgh VA, close to where I live, in my 
district, and I believe they were treated there in some cases.
    And so I was curious, when that happens--I'm assuming it's 
probably happened in other places around the country, where 
they notice a problem, they look to nearby VAs to cover the gap 
in the meantime--is there a mechanism to make sure that the VA 
who's covering, in this case the Pittsburgh VA, gets additional 
resources or gets additional tools that they need to cover that 
new influx of patients? How is that handled?
    Ms. Taylor. That's a great question. I think, typically, 
the receiving VA will determine that they have the capacity to 
assume that additional workload, those additional patients. And 
so they will actually reach out and say, ``We can do this.'' So 
they may not receive any additional support, because they have 
determined that they have the capacity to take--
    Mr. Lamb. So they basically volunteer if they're able to do 
it.
    Ms. Taylor. Uh-huh.
    Mr. Lamb. Okay. Thank you.
    Ms. Taylor. Yes, sir.
    Mr. Lamb. Ms. Silas, you mentioned in your testimony that 
at least part of the problem here was a shortage of employees. 
And I think you mentioned something about a lack of overtime 
pay for those who were remaining and who were working on some 
of these issues. Could you just elaborate on that a little bit 
more?
    Ms. Silas. Certainly. I did note that there was an issue 
with overtime. I didn't speak specifically about the overtime 
pay.
    Mr. Lamb. Sure.
    Ms. Silas. But it was something that we heard consistently 
across both our interviews with the VISN officials and at the 
facility level, that staff were often asked to work overtime 
and that that could potentially result in issues with delays in 
processing the reusable medical equipment.
    Mr. Lamb. And can you just--what is it exactly that you 
heard? Can you explain that to me? Because it sounds like, if 
they're asking them to work overtime, someone's working on the 
problem. So what's the issue?
    Ms. Silas. Yeah, that there was a number of vacancies, and 
so then they were asked to work overtime to fill for those 
vacancy spots. So there wasn't enough numbers of staff in the 
program itself to make sure that the equipment was being 
processed.
    Mr. Lamb. Okay.
    And, Mr. Daigh, I just wanted to ask you to elaborate a 
little bit on your comments that you think the VA's 
administrative alignment is outdated these days. Can you talk a 
little bit about the cause and effect? Like, what's the cause 
of the failure to comply with sterile processing procedures 
from an administrative standpoint?
    Dr. Daigh. So, it seems to me that an operating room's 
function is pretty basic to the operation of a hospital. And, 
it seems to me, that the staffing of SPS, sterile supplies, 
staffing of logistics, the pre-check to make sure you have the 
equipment that Dr. Roe spoke of, should all occur every day, 
all the time without any interruption.
    When we go to the VA hospital in D.C., we found that a 
number of services that were business offices were critically 
understaffed. Something like--I have to make this up, but, 
like, half of the people in SPD were not on the books; a 
significant portion of the people in logistics were not on the 
books.
    So, if you're running a hospital where the only metric you 
look at is infection rate, for example, that's a good metric to 
look at, but it doesn't speak to the business operation of what 
you're really trying to do.
    So, the short answer is I think the director of a hospital 
ought to take whatever action is needed to make his operating 
room or her operating room run efficiently. And, if you need 
SPD people, then you hire SPD people. If you need logistics 
people, you hire logistics people. And if you can't get it 
done, then you go up and talk to the next level of command and 
say, ``I need help.'' And if they can't get it done, they come 
to you and say, ``I need help.''
    So, I think this particular problem, I think that at a 
national level, whether they're going to buy software, for 
example, or whether they're going to have--the government has 
certain standards about, you know, classification of people--I 
think that's all a national issue. But the actual--just making, 
you know, juice out of oranges every day, that has to work well 
at the local level.
    So, I have a very hard time understanding why these 
problems continue to exist. They do exist.
    If you go back to 2009, one of the more interesting 
features of the episode that we had where VA's colonoscopy 
equipment was not being properly reused or recleaned, the Under 
Secretary for Health sent out a directive to everyone in the 
field and said, we want you to do this. And, it laid out an 
organizational structure and a few things they were supposed to 
do. We went out about 6 months later and checked to see if 
they'd done that, and people just really hadn't.
    One of the problems VA has is that health care is local. 
Well, local is great unless you're trying to provide a standard 
benefit that the government wants to provide to everyone in the 
country. You need people in small places to do what the Under 
Secretary of Health says every time. You have to see that.
    So, your hospital is wired differently than--and it has a 
different organizational chart than the hospital in 
Indianapolis, then the hospital in D.C. So, all of these lacks 
of standards make it difficult for Central Office to 
communicate effectively with the field and get things done.
    So, I think it's a system that really needs to be 
redesigned and thought through, who should be responsible for 
this and that and then given the right authorities and then 
allowed to do that.
    I find VISNs to be very ineffective every time I look to 
see what VISNs might do. Maybe--since I only get called to see 
problems--maybe they're doing things I'm not aware of. That's a 
possibility. But I don't find them to be, you know, the savior 
at the end of the day to solve a problem or prevent something 
from happening.
    Mr. Lamb. Thank you, sir. We seem to hear that a lot as 
well.
    Mr. Chairman, thank you.
    Mr. Bergman. Thank you.
    We heard Dr. Roe talk about what it was like to be the 
surgeon handling the instruments. My first career, after 7 
years of active duty in the Marine Corps, was in the surgical 
instrument business.
    So let's talk about the end of the case, when the patient's 
already left the room, going out into recovery, and they're 
taking all the instrument trays, whether they're going back for 
processing to go into an autoclave or they're going to go into 
a sterile soak, whatever they happen to be doing, but they're 
all going to leave that O.R. They're going to probably go on a 
cart, whether it gets on an elevator or down a hallway, into 
central supply. ``Central sterile supply'' it used to be called 
a long time ago.
    The point is, would anybody venture a guess at the table 
how many of your medical center directors have ever spent any 
time in central supply, gloved up, understanding the difference 
between what it means to clean the box lock of a hemostat as 
opposed to the canula around an optical head? I mean, would 
anybody want to venture a guess, how many of your medical 
center directors know the details? Not that they're proficient 
in all of them, but they've actually hands-on observed or 
whatever it is?
    Ms. Taylor. Sir, speaking as a former nurse executive, I 
can share that all of the directors that I worked with would 
accompany me from time to time, whether it's on environment-of-
care rounds, whether it's just rounding to visit the staff--
    Mr. Bergman. Okay, so they know how it works. So there's 
nobody sitting up in the corner office not having a clue how it 
works. So you're saying you're vouching for all your medical 
center directors, that they know how things are supposed to go 
on in central supply.
    Ms. Taylor. The ones I worked with, yes, sir, they did.
    Mr. Bergman. Okay.
    So then if you're the captain of that ship, if you will, 
you're the director of that medical center, and you know that 
to eliminate that infection rate because of the use of a dirty 
instrument is going to ensure better outcomes for your VA 
patients, why aren't the directors of the medical centers who 
have a sterile processing unit within their building confines, 
why are they not like, you know, a pit bull on your ankle when 
it comes to getting it right?
    Ms. Taylor. Well, sir, again, I'll speak to the directors 
that I have worked with. And they have been pit bulls, a few of 
them.
    Mr. Bergman. So then what I hear, the VISN is part of the 
problem, not part of the solution. So, if I'm the medical 
center director, the VISN is somewhere else in another city, I 
know I'm responsible for the outcome of my patients. What's 
inhibiting the medical center directors from just taking the 
bull by the horns and making sure that those standards are 
adhered to and those instruments are clean?
    Ms. Taylor. I'd like to make one point of clarification, 
because we've mentioned ``dirty instruments in the O.R.'' And I 
believe it's important to make the distinction that between 
``dirty instruments going to the O.R.'' and ``one step in one 
process for one piece of equipment or instrumentation is missed 
and therefore we are not compliant with an SOP.''
    I think how we are measured is if we're completely 
compliant with our standard operating procedures. In a 1A 
facility where I worked for the past couple of assignments, we 
had anywhere from 200 to 250 standard operating procedures, 
each of which may have up to 150 steps. So--
    Mr. Bergman. Okay. So have we got too many procedures, I 
mean, too many steps, too many compliance steps? Because you've 
got someone who actually physically has to handle that 
instrument--
    Ms. Taylor. Yes, sir.
    Mr. Bergman [continued].--whether it be in an instrument 
tray or whether it be just a separate instrument as in an 
endoscope.
    Ms. Taylor. That's right.
    Mr. Bergman. So they're the ones that are ultimately hands-
on, they're the eyeballs-on. They have their procedures to 
check exactly if that instrument passes muster to go back into 
a sterile tray, then to go back into the sterilization process, 
then to go back into the O.R.
    Ms. Taylor. Correct.
    Mr. Bergman. So what's inhibiting that it would--do I hear 
you saying we have too many compliance--
    Ms. Taylor. No. I was attempting to put the noncompliance 
in context. It's simple, as was stated before, but simple 
doesn't equate to easy. And when you have--
    Mr. Bergman. But is someone training--if I'm the person, if 
I'm that new person that you've just hired--
    Ms. Taylor. Yes.
    Mr. Bergman.--and you're teaching me how to clean that 
instrument and you're my supervisor, or you're that third-party 
training entity--don't care, because companies who manufacture 
those instruments, they provide expertise to come in there and 
train the people not only how to use the instrument in the O.R. 
but also how to clean the instrument so it's ready to use 
again.
    So whoever is responsible for the training of that 
individual, I mean, are we missing something here?
    Ms. Taylor. I don't believe we're missing something.
    And to go back to a question that was asked a little bit 
earlier about the history, in '09 when the issue was raised 
initially or when we really had a lot of discussion about this, 
again, I was a nurse executive in the field. We had very few, 
if any, standard operating procedures. We had very little 
guidance. We did not have--
    Mr. Bergman. Hold on.
    Ms. Taylor [continued].--many structures.
    Mr. Bergman. Hold on.
    Ms. Taylor. So we--
    Mr. Bergman. Hold on. Just hold on here.
    Ms. Taylor. Sure.
    Mr. Bergman. VA medical centers aren't the only hospitals 
in the world--
    Ms. Taylor. Correct.
    Mr. Bergman [continued].--okay? And in my district, I have 
Dickinson County Memorial Hospital, a county hospital, four 
blocks from the VA hospital. They do the same procedures, in a 
lot of cases. And they're going to have two separate, you know, 
central sterile processing departments.
    Are you saying that outside the VA system there's not 
enough data, not enough standardization procedures that we can 
just take what's working in another hospital somewhere--are we 
reinventing the wheel here?
    Ms. Taylor. I don't believe we're reinventing the wheel, 
sir. But I can say that our national office has actually been 
asked to consult with the joint commission as they review 
sterile processing services not only within the VA but also in 
the private sector, because they do believe that the approach 
that we have taken is the most thorough.
    Mr. Bergman. Well, you know what? When you have a veteran 
who's getting a procedure done today, and if they have to think 
that they're assuming risk--again, I'll use Iron Mountain, 
Michigan, as the example--that they're assuming unnecessary 
risk by going to the Kingsford VA Hospital as opposed to going 
to Dickinson County Hospital, that's shameful. It's the wrong 
thing. And if that's what we're saying in the VA, we have to do 
more paperwork and add more--you know, the VISNs involved and 
all that, then we've totally missed the boat here.
    So you guys are the messengers. You know that. Every time 
we have one of these hearings, you come in here and you take 
the spears.
    Ms. Taylor. Yes, sir.
    Mr. Bergman. And the point is we, and all on this 
Committee--it doesn't make any difference which side you sit 
on--we want to make sure the veterans don't get infections 
because instruments aren't cleaned.
    So I will yield back.
    Mr. Peters, would you like to ask a second round of 
questions?
    Mr. Peters. I just have one more question--
    Mr. Bergman. Okay.
    Mr. Peters [continued].--which is an indirect question. And 
it has to do with facility maintenance issues, particularly in 
older facilities that lack proper ventilation. I know that this 
has been an issue with respect to infections as well.
    Do you have the resources at the VA to address the 
deficiency when they're identified during the inspection? And 
do you know how much is budgeted for VHA to address this 
problem?
    Dr. Boyd. So, for the first part of that question--and 
that's a very good question, because one of the areas that we 
found early on this year was that we really needed to match up 
what goes on in the engineering portion in our infrastructure, 
in our facilities, the facilities management, because their 
activities, whether it be regular maintenance or flushing pipes 
or changing steam traps or whatever, that affects SPS processes 
for that day. And so those two people need to--those two 
services need to talk. So, very important, especially within 
our infrastructures that are aging.
    The second part of your question, I am not aware of that 
information--I do not have that information, but it's something 
that we could get back to you on. It would be someone else that 
I'd have to ask about that budgetary line item.
    Mr. Peters. Yeah, that would be very helpful. I appreciate 
that.
    Ms. Taylor. Absolutely.
    Mr. Peters. And I would yield back. Thank you, Mr. 
Chairman.
    Mr. Bergman. Thank you.
    Dr. Roe, you're recognized.
    Mr. Roe. Thank you.
    Just a couple of questions. One, just to reassure people, 
most situations, people going to the operating room at a VA 
hospital is perfectly safe. I want people to understand that. 
These are the outliers that we're talking about today.
    And I think Dr. Daigh hit the nail right on the head when 
he was talking about this really is a local issue, it's a local 
situation, not to a VISN or to the central office; this is very 
basic operation of a hospital. And it is to mean these 
procedures are there for a reason. They're to protect people. 
And like you said, that doesn't make them simple. These can be 
very complex things to do. But they're there for a reason, and 
they're there for patient safety.
    And so I think the responsibility lies absolutely with each 
individual hospital director and the director of the O.R. I 
mean, it's not any more complicated than that. Doesn't need to 
be up here; we don't need to be hearing about it. It needs to 
be taken care of at the local level.
    And with that being said, how do you evaluate the 
performance of a director who's responsible, for instance, for 
the VA Washington Medical Center? I've heard about the VA 
Medical Center in Washington, D.C., since I've been here, for 
10 years.
    Ms. Boyd. So, great question. And, actually, that goes back 
to one of my earlier comments. I absolutely agree with Dr. 
Daigh. We really need to push rights and responsibilities and 
authorities down to the lowest level possible. And, in this 
case, it is at the front line. That's where we take care of our 
veterans every day.
    And really to the meat of your question, this year, we 
have, in a validation--a timeline right now, we're looking at: 
What would be those four metrics that would be conversation 
starters? In other words, it would be a high-level way for us 
to get kind of a sniff test that maybe this medical center is 
not up to snuff with regards to their SPS working. So we have 
four metrics in prototype that we're looking at to validate to 
see if in fact it's what we need.
    In my office, we will be using that with our network 
directors, first of all--not solely--but communicating to them 
about their medical centers as well. But then we'd be using 
that with each medical center as well. And it will allow us to 
become over time a more predictive model, we hope, a more 
reliable tool to determine if there are some, you know, early 
warnings signs of something going astray.
    So this is the administrative SAIL metrics for SPS, and we 
look forward to coming back and letting you know how that's 
working. But we really do need that model and that conversation 
with it.
    Mr. Roe. Oh, I think it's pretty simple. I mean, if you've 
got a hospital that can't get--with the funding we've put out 
there. And as Mr. Peters said, are there needs out there we 
need to know about? We need to know about it; we'll provide 
those resources. But I think if you don't, you've got to 
replace your medical center director. I mean, that's so simple 
and basic that it doesn't need to go a VISN or central office. 
That person needs to do something else, they need to be in a 
different line of work if they can't get that done.
    Mr. Chairman, I hope that this is the last we have to hear 
about this. I hope this is fixed. And, you know, I have never 
had an operation in my life, and I had two major ones done on 
me in the last 2 years. And it never dawned on me that I have 
to worry about whether the equipment was sterile. That was the 
least of my worries. That should be the least of any patient's 
worries.
    I yield back.
    Mr. Bergman. Thank you.
    Dr. Boyd, we were told at our May 22nd hearing on VISN 
restructuring that VA would complete its VISN reorganization 
plan by July 1st. It's now early in September, that would be 
the 5th. And GAO's report highlights more shortcomings in VHA's 
governance structure.
    What is the status of the VA's efforts to reform the VISNs, 
and when will we be given the plan?
    Dr. Boyd. So we have mentioned VHA governance restructuring 
and the discussion about VISNs. With our new Secretary now on 
board, I do believe--I know he was briefed just very recently, 
in the past few days, about the work to date. And so we are 
awaiting his discussion and his feedback, his recommendations 
to move forward.
    Mr. Bergman. Okay. Can you give me a date when we might, 
you know, see this information? I mean, can you provide any 
insight into the changes that Secretary Wilkie could 
potentially be considering?
    Dr. Boyd. I wish I could, but I do not have any knowledge 
of that.
    Mr. Bergman. Okay. Well, do you get a chance to meet with 
Secretary Wilkie?
    Dr. Boyd. I have yet to have a one-on-one meeting with him, 
sir. I do meet with our executive in charge, Dr. Rich Stone, at 
the VHA level.
    Mr. Bergman. Well, maybe we could facilitate a one-on-one 
for you, because then you can pass along to Secretary Wilkie. 
And we've talked about this--the urgency or lack of urgency 
within, if you will, the bureaucracy to get to an end game, 
which we all agree we have to get to sooner rather than later.
    Because if you reduce infections, you increase the quality 
of care and the recovery and reduce the overall cost. So it's a 
win-win for us to tackle. And the case is us, you, VA. And when 
I include the ``us,'' I could potentially be that patient on 
your table, and I want to make sure, as Dr. Roe said, I don't 
have to think about are the instruments clean.
    If you don't assume the mission and take control of it and 
take responsibility for it, we're going to be having hearings 
like this again. We don't want that. We have identified the 
problem. There's no wondering what the problem is. The question 
is how and how quickly do we move forward with logical 
solutions.
    So the ball's in your court. And we need, as in ``we,'' all 
of the veterans and all of the families of veterans, need a 
response to solving the problem. Okay?
    And as Dr. Roe said, a medical center director shouldn't 
have to go to the VISN to ask permission, or whatever it is, to 
run their own backyard, their own operation.
    So, anyway, having said that, I'd like to thank all of you 
for your testimony today.
    Before I close, I'd like to point out that today was the 
first time that Ms. Silas testified before Congress.
    Is that true?
    Ms. Silas. Yes.
    Mr. Bergman. First time. Okay. You look forward to coming 
back, right? Okay. But, you know, you did an excellent job of 
representing GAO. And I'm sure you will be asked, if not 
dragged, to come back here, you know, at some point in the 
future.
    But, you know, with that, the panel is now excused.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    Without objection, so ordered.
    Mr. Bergman. I once again would like to thank all of our 
witnesses and the audience members for joining us here this 
morning.
    And the hearing is now adjourned.

    [Whereupon, at 11:14 a.m., the Subcommittee was adjourned.]

                           A P P E N D I X

                              ----------                              

                Prepared Statement of Dr. Teresa D. Boyd
    Good morning Chairman Bergman, Ranking Member Kuster, and Members 
of the Subcommittee. I appreciate the opportunity to discuss the 
Department of Veterans Affairs (VA) Sterile Processing Services (SPS) 
programs in respect to reusable medical equipment (RME). I am 
accompanied today by Dr. Beth Taylor, Deputy Assistant Deputy Under 
Secretary for Health (USH) for Clinical Operations.
    VA's Veterans Health Administration (VHA) operates one of the 
largest health care delivery systems in the Nation, serving over 9 
million Veterans. In providing health care services to Veterans, VA 
medical centers (VAMC) use RME which must be reprocessed between uses. 
Reprocessing refers to the cleaning, disinfecting, or sterilization of 
RME, such as surgical instruments or endoscopes. Due to the increasing 
complexity of device designs and components, reprocessing has become 
much more complicated and time consuming. Improper reprocessing creates 
potential risks, like infection, and can adversely affect timely access 
to care, such as delayed or canceled surgeries due to the lack of 
properly reprocessed RME. The SPS programs within each VAMC provide 
oversight and manage reprocessing within their respective facility. To 
help ensure patient safety, VHA policy establishes requirements VAMCs 
must adhere to when reprocessing RME. Further, VHA policy requires 
inspections to be completed each year to determine the extent to which 
VAMCs are following said requirements and that incidents involving 
improperly reprocessed RME are reported.
    On June 8, 2018, the U.S. Government Accountability Office (GAO) 
provided VA with a draft report entitled ``VA HEALTH CARE: Improved 
Oversight Needed for Reusable Medical Equipment.'' In the report, GAO 
states that VHA does not have reasonable assurance that VAMCs are 
following policies related to reprocessing RME. Further, the report 
contends that VHA has not ensured that all VAMC RME inspections have 
been conducted because it has incomplete information from the annual 
inspections from the Veterans Integrated Service Networks (VISN) which 
oversee VAMCs. GAO also found that VAMCs face challenges operating 
their SPS programs, notably addressing workforce needs. The report 
resulted in three recommendations that VHA agreed to implement to 
further strengthen the SPS programs and solidify patient safety 
standards.
    GAO recommended that the USH ensure all RME inspections are being 
conducted and reported as required and that the inspection results VHA 
has are complete. VHA fully concurs with this recommendation. The 
National Program Office for Sterile Processing (NPOSP) will establish 
an oversight process for reviewing and monitoring findings from site 
inspections and reporting to VA Central Office leadership. NPOSP's 
oversight process will include follow-up and feedback loops with VISNs 
on their oversight of facility corrective action plans. The Office of 
the Deputy USH for Operations and Management will ensure SPS and RME 
issues are reported to a National RME Committee advisory group for risk 
assessment and response. The target completion date of July 2019 
reflects implementation of the new oversight and governance processes 
and time for data collection.
    GAO recommended that the USH consistently analyze and share top 
common RME inspection findings and possible solutions with VISNs and 
VAMCs. VHA fully concurs with this recommendation. NPOSP will analyze 
data from site inspections; identify trends or risks; develop possible 
solutions in collaboration with VISNs; and provide a written briefing 
to the National RME Committee, VISNs, and facilities. NPOSP will 
publish the briefing and possible solutions on the NPOSP Web site with 
a target completion date of July 2019. Additionally, NPOSP will 
communicate the report with the VISN and VAMC leadership through 
current educational sessions and national calls.
    Lastly, GAO recommended that the USH examine SPS workforce needs 
and take action based on this assessment, as appropriate. VHA fully 
concurs with this recommendation. The VA Workforce Management and 
Consulting (WMC) Office is championing an interdisciplinary work group 
with NPOSP, the VA Office of Nursing Service (ONS), and the VA Quality, 
Safety, and Value (QSV) High-Reliability Systems and Consultation 
Service. The work group has identified actions to address the SPS 
workforce needs including: a revised qualification standard that will 
encompass a specified assignment for a VISN SPS Program Manager; 
implementation of an enhanced market-based approach to pay; and 
establishment of an occupational-specific recruitment and development 
infrastructure. Additionally, WMC will provide workforce related data, 
as available, to assist partners in ONS, NPOSP, and QSV in their 
development of a staffing model for the occupation. This will allow 
VAMCs and health care systems to appropriately determine resources 
needed to more effectively execute mission requirements. This 
initiative has a target completion date of December 2018.
    The VA Office of Inspector General (OIG) released a report in March 
2017 entitled ``Critical Deficiencies at the Washington DC VA Medical 
Center.'' The report mentioned a myriad of concerns, including SPS 
issues. However, despite these issues, the Washington, DC VAMC has 
lower infection rates than that of the overall industry. In fact, the 
rolling 12-month surgical site infection (SSI) rate for all surgical 
procedures assessed under the VA Surgical Quality Improvement Program 
ending March 31, 2018, is 1.41 percent nationally, whereas the SSI rate 
for the Washington, DC VAMC for the same time period is 1.09 percent. 
Notably, these are both lower than the most recent data on infection 
rates industry-wide, which found an SSI rate of 1.9 percent.
    OIG made several recommendations and VHA concurred in full and has 
since taken action. The Washington, DC VAMC Acting Medical Center 
Director, in collaboration with NPOSP, and the VISN 5 Patient Safety 
Officer, developed a Quality Assurance process which was implemented on 
November 2, 2017, to verify the cleanliness, functionality, and 
completeness of instrument sets to ensure that the sets are available 
when needed. Any non-conformities are communicated to SPS in real time 
as well as data collected and aggregated. The Quality Assurance staff 
representative for SPS meets with the Chief of SPS twice weekly to 
review Quality Assurance monitors.
    Moreover, a new policy regarding the proper reprocessing of loaner 
instruments and trays was developed, published, and communicated to 
staff through training during staff meetings. The policy was also 
reviewed by the facility RME Committee, who is charged with 
responsibility for monthly tracking of policy compliance. There is 
currently a process for reporting all non-conformities in the RME 
Committee meeting; these data are reviewed monthly. Also, SPS will 
report to the RME Committee monthly regarding the maintenance of 
readily-accessible standard operating procedures for all instruments 
and equipment within SPS and its satellite areas in accordance with VHA 
policy. Compliance with standard operating procedures completion will 
be validated through facility and VISN-led inspections as well as 
through the monthly RME Committee.
    Lastly, SPS will report to the RME Committee monthly regarding the 
status of competencies and proficiencies of the SPS employees. Ongoing 
compliance with competencies will be validated by competency audits 
incorporated into facility and VISN-led SPS inspections. Staff from the 
NPOSP provided on-site training to all SPS staff, including contract 
technicians, during the week of December 4, 2017. Since that training, 
there are staff trained with appropriate competencies to work in all 
areas where RME reprocessing is occurring. Competency validation, 
however, is an ongoing process. New staff, as part of their 
orientation, will have appropriate training and competency validation 
prior to independently performing reprocessing. As new equipment or 
instrumentation is acquired and as standard operating procedures are 
updated and/or implemented, staff members who use the equipment or 
instrumentation will have training with competency validation. The 
Washington, DC VAMC remains committed to patient safety and the well-
being of our Veterans.
    VHA is strongly committed to developing long-term solutions that 
mitigate risks to the timeliness, cost-effectiveness, quality, and 
safety of the VA health care system. VHA will use these findings to 
continue to make improvements and fulfill our mission of honoring 
America's Veterans by providing exceptional health care that improves 
their health and well-being.
    NPOSP is dedicated to sustainable corrective actions. This is 
achieved through communication, education, and training, as well as 
commitment to collaborative policy changes with key stakeholders which 
include workforce management and consulting, logistics, contracting, 
facilities management, risk management, and patient safety.
    As evidence of VHA's commitment to sustainable improvements, NPOSP 
has implemented several actions to enhance the reporting of findings 
and improve communication with the field, VISN, and national 
stakeholders to provide support for the success of SPS programs. These 
actions include: updating NPOSP-led triennial audit/ action plans every 
60 days until all non-conformities identified by the audit have been 
completed; follow up on all issue briefs relating to SPS every 30 days 
until closed; and maintaining regular calls with SPS-challenged 
facilities; and organizing a variety of communication methods and 
forums to share trends. NPOSP is also in the process of leading a 
national initiative consisting of a point-in-time audit, follow-up 
training, and a VISN audit - all occurring in the next 90 days. These 
events will assist in establishing reliability of the SPS audit tool 
and ensure NPOSP has a complete and accurate data set indicating the 
current performance of all SPS facilities. To assist in identifying 
facilities at risk, NPOSP is developing a risk assessment tool that 
will be available for testing in approximately 90 days.
    NPOSP recognizes deficiencies and is aggressively creating cultural 
changes in quality improvement processes, as well as strengthening 
executive communication with all levels of executive leadership in 
order to expedite effective change and accountability.
    VA is leveraging long-standing staffing models for primary care, 
mental health, and nursing and is developing, evaluating, and refining 
additional staffing models for other functional areas. VA will continue 
to evolve its clinical staff modeling and workforce planning for other 
practice areas such as SPS.
    Additionally, VA is establishing a manpower-capacity tracking 
system for the entire Department and is committed to deploying a 
position management solution for both clinical and non-clinical 
requirements. An updated, efficiently-aligned position categorization 
structure will enable VA facilities to more precisely define their 
clinical and non-clinical staffing requirements. Such a structure will 
also enable staffing predictive power on the part of VAMCs and VISNs.
    SPS programs have significantly improved the efficiency and safety 
of health care of our Veterans. Patient safety and infection control 
will be improved because surgical instruments are being reprocessed 
correctly. In order to sustain these efforts, we ask Congress for 
continued support of VA modernization. It is critical that we continue 
to move forward with the current momentum and preserve the gains made 
thus far. Your continued support is essential to providing care for 
Veterans and their families. Mr. Chairman, this concludes my testimony. 
My colleague and I are prepared to answer any questions.

                                 
                   Prepared Statement of Sharon Silas
Improvements in Oversight Needed for Reusable Medical Equipment

    Chairman Bergman, Ranking Member Kuster, and Members of the 
Subcommittee:

    I am pleased to be here today to discuss the use of reusable 
medical equipment (RME) in the Department of Veterans Affairs (VA). As 
you know, VA's Veterans Health Administration (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, VA medical centers use RME, such as endoscopes and surgical 
instruments, which must be reprocessed-that is, cleaned, disinfected, 
or sterilized-between uses. \1\ The proper reprocessing of surgical 
instruments and other RME used in medical procedures is critical for 
ensuring veterans' access to safe care. Accordingly, VHA policy 
establishes requirements VA medical centers must follow when 
reprocessing RME to help ensure the safety of veterans who receive care 
at its facilities.
---------------------------------------------------------------------------
    \1\ An endoscope is an instrument used for direct visual inspection 
of hollow organs or body cavities.
---------------------------------------------------------------------------
    Nevertheless, VHA has had ongoing challenges related to properly 
reprocessing RME. For example, in 2011 we found that VHA had not 
provided sufficient guidance to VA medical center staff operating the 
Sterile Processing Services (SPS) programs to ensure that staff were 
reprocessing RME correctly, which posed potential safety risks to 
veterans. \2\ In 2016, the VHA Office of the Medical Inspector reviewed 
and corroborated allegations that the SPS department at one VA medical 
center failed to provide surgeons with RME free of bioburden, debris, 
or both. \3\ Further, in March 2018, the VA Office of Inspector General 
reported on problems at another VA medical center including delayed and 
cancelled procedures due to the fact that the necessary RME had not 
been properly reprocessed and were therefore unavailable. \4\
---------------------------------------------------------------------------
    \2\ The VA medical center SPS programs consist of the SPS 
department, which has primary responsibility for reprocessing RME, and 
other areas such as dental clinics, where certain reprocessing 
functions occur. See GAO, VA Health Care: Weaknesses in Policies and 
Oversight Governing Medical Supplies and Equipment Pose Risks to 
Veterans' Safety, GAO 11 391 (Washington, D.C.: May 3, 2011). We 
recommended that VA develop and implement an approach for providing 
standardized training for reprocessing all critical and semi-critical 
RME to VA medical centers and that VA hold VA medical centers 
accountable for implementing device-specific training for all of these 
RME. VA concurred with this recommendation, and, in November 2012, 
stated that over 1,200 employees had been certified by a professional 
organization dedicated to the education and certification of SPS 
employees. In addition, in March 2016, VA implemented a policy which 
requires, among other things, standardized training for reprocessing 
RME and oversight of reprocessing activities.
    \3\ Bioburden is a measure of an object's microorganism 
contamination. See Department of Veterans Affairs, Department of 
Veterans Affairs Cincinnati Veterans Affairs Medical Center Cincinnati, 
Ohio, Veterans Integrated Service Network 10, TRIM 2016-D-1082 
(Washington, D.C.: May 8, 2016).
    \4\ See Department of Veterans Affairs, Office of Inspector 
General, Veterans Health Administration, Critical Deficiencies at the 
Washington DC VA Medical Center, Report #17-02644-130 (Washington, 
D.C.: Mar. 7, 2018).
---------------------------------------------------------------------------
    My testimony today summarizes the findings from our August 2018 
report that analyzed VA's oversight of reusable medical equipment. \5\ 
Accordingly, this testimony addresses
---------------------------------------------------------------------------
    \5\ See GAO, VA Health Care: Improved Oversight Needed for Reusable 
Medical Equipment, GAO 18 474, (Washington, D.C.: Aug. 3, 2018).

    1.VHA's oversight of VA medical centers' adherence to RME policies, 
---------------------------------------------------------------------------
and

    2.challenges VA medical centers face in operating their SPS 
programs and efforts VHA has taken to address these challenges.

    As part of my testimony, I will highlight the three recommendations 
we made to VA to improve its oversight of RME and ensure access to safe 
care for veterans. VA concurred with all three of the recommendations 
and said it would take actions to implement them.
    To conduct the work for our August 2018 report, we reviewed VHA RME 
policy as well as other documents such as VHA Directive 1116(2), which 
describes RME policy requirements and instructions for how inspections 
of VA medical centers' adherence to these requirements should be 
conducted. \6\ We also reviewed VHA summary data on inspections of VA 
medical centers conducted by their respective Veterans Integrated 
Service Networks (VISN) in fiscal year 2017. \7\ We reviewed the full 
inspection reports provided by the VISNs for inspections the VISNs had 
conducted in fiscal year 2017, but for which VHA did not have a record, 
and identified information about nonadherence to RME policy 
requirements. In addition, we interviewed VHA officials, officials from 
all 18 VISNs, and officials from four VA medical centers selected for 
our review. \8\ As part of our review, we assessed VHA's oversight 
efforts and its efforts to address any identified RME-related 
challenges in the context of federal standards for internal control. 
\9\ Further details regarding the scope and methodology of our work are 
included in our August 2018 report. The work on which this statement is 
based was performed in accordance with generally accepted government 
auditing standards.
---------------------------------------------------------------------------
    \6\ See VHA Directive 1116(2), Sterile Processing Services (SPS) 
(Washington, D.C.: Mar. 23, 2016). See Department of Veterans Affairs, 
Deputy Undersecretary for Health for Operations and Management (10N), 
10N Guide to VHA Issue Briefs (Washington, D.C.: June 26, 2017).
    \7\ VISNs are responsible for ensuring adherence to VHA's policies 
among the VA medical centers within their region.
    \8\ We selected the four VA medical centers to achieve geographic 
and medical center complexity variation and the highest and lowest 
performance regarding operating room lag time. VHA assigns each VA 
medical center to one of five complexity groups based on patient 
population served, clinical services offered, education and research 
complexity, and administrative complexity. Operating room lag time data 
captures the time elapsed from one patient leaving and the next patient 
entering the operating room; lag time can be attributed to RME not 
being available, among other factors. The four VA medical centers we 
selected were located in Chicago, IL; Erie, PA; Fort Meade, SD; and 
Little Rock, AR. We were not able to speak with the Chief of SPS at the 
Chicago Jesse-Brown VA medical center; as such, some of our reported 
results are for three VA medical centers.
    \9\ See GAO, Standards for Internal Control in the Federal 
Government, GAO 14 704G (Washington, D.C.: September 2014). Internal 
control is a process effected by an entity's oversight body, 
management, and other personnel that provides reasonable assurance that 
the objectives of an entity will be achieved.

VHA's Oversight Does Not Provide Reasonable Assurance That VA Medical 
---------------------------------------------------------------------------
    Centers Are Following RME Policies

    In our August 2018 report, we found that VHA had not ensured that 
it has complete information from the annual inspections VISNs conduct. 
VISNs are required to conduct annual inspections at each VA medical 
center within their VISN and to report their inspection results to VHA. 
These inspections are a key oversight tool providing the most current 
information on adherence to RME policies VA-wide, as VHA does not 
inspect every VA medical center each year. 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 objective. \10\ Without complete information from these 
inspections, VHA cannot reasonably ensure that VA medical centers are 
following RME policies intended to ensure veterans are receiving safe 
care.
---------------------------------------------------------------------------
    \10\ See GAO 14 704G.
---------------------------------------------------------------------------
    For fiscal year 2017, we determined that VHA was missing 39-or more 
than one-quarter-of the required VISN inspection reports. \11\ VISN 
officials suggested several reasons for the missing reports. For 
example, an official from one VISN provided evidence that the VISN had 
conducted almost all of its inspections, but told us the VISN did not 
submit reports to VHA because it has yet to receive information from 
VHA regarding VISN inspection outcomes, common findings across VISNs, 
or best practices and therefore the VISN sees no value in submitting 
the reports. A VHA official told us the office had not been aware that 
it did not have all of the required VISN inspection reports because it 
has largely relied on the VISNs to monitor inspections since VHA does 
not have sufficient resources to do so itself.
---------------------------------------------------------------------------
    \11\ VISNs were able to provide GAO with evidence that they had 
conducted 27 of the 39 missing inspections.
---------------------------------------------------------------------------
    We also found in our report that VHA does not consistently share 
information, particularly inspection results, with VISNs and VA medical 
centers, and that VISNs and VA medical centers would like more of this 
information. Specifically, about two-thirds of the VISN and VA medical 
center officials we interviewed told us that sharing information on the 
common issues identified by VA medical center inspections as well as 
potential solutions developed to address these issues would allow the 
VA medical centers to be proactive in strengthening their adherence to 
RME policies and ensuring patient safety. For example, one VA medical 
center official we interviewed told us that there were problems with 
equipment designed to sterilize heat- and moisture- sensitive devices, 
and that seeing how other VA medical centers addressed the problem 
would be helpful. Further, officials from some VISNs we interviewed 
said VHA cited their VA medical centers for issues that had been found 
at other facilities and that, had they been aware of the issue 
beforehand, they could have corrected or improved their processes for 
adhering to RME policies.
    When asked about sharing inspection results and other information, 
VHA Central Office officials told us the office does not analyze or 
share VISN inspections information due to inadequate resources. More 
specifically, one VHA official told us that the office does create an 
internal report of common issues identified through the third of VA 
medical centers it inspects each year, but does not share this report 
with VISNs and VA medical centers because the office lacks the 
resources needed to prepare reports that are detailed enough to be 
correctly understood by the VISN and VA medical center recipients. 
According to this official, VHA has occasionally shared information 
regarding common inspection issues through newsletters, national calls, 
and trainings. However, VHA officials we interviewed at 8 of the 18 
VISNs and 1 of the 4 VA medical centers we reviewed said that they 
rarely or never received such information. For example, officials from 
one VISN told us that they recall just one or two instances where VHA 
sent a summary of the top five RME-related issues found during VHA 
inspections. Insufficient sharing of information is inconsistent with 
standards for internal control in the federal government regarding 
communication, which state that management should internally 
communicate the necessary quality information to achieve the entity's 
objectives. \12\ Until this sharing becomes a regular practice, VHA is 
missing an opportunity to help ensure adherence to its RME policies, 
which are intended to ensure that veterans receive safe care.
---------------------------------------------------------------------------
    \12\ See GAO 14 704G.
---------------------------------------------------------------------------
    Based on our findings, in our August 2018 report we recommended 
that VA take steps to ensure that all RME inspections are being 
conducted and the results of those inspections are reported to VHA as 
required. We also recommended that VA consistently analyze and share 
top common RME inspection findings and possible solutions with VISNs 
and VA medical centers. VA concurred with these recommendations and 
said it would establish an oversight process for reviewing and 
monitoring findings from RME inspections and for reporting this 
information to VHA leadership. Further, VA noted that VHA will analyze 
data from RME inspections and share findings and possible solutions 
with VISNs and VA medical centers via a written briefing.

VA Medical Centers Reported Facing Challenges Related to RME Policies 
    and Workforce Needs, but VHA Has Not Sufficiently Addressed These 
    Challenges

    We also found in our August 2018 report that the top challenges VA 
medical centers face in operating their SPS programs were related to 
meeting certain RME policy requirements and challenges addressing SPS 
workforce needs. Regarding the challenges VA medical centers face in 
meeting RME policy requirements, the majority of the 18 VISN and four 
selected VA medical center officials interviewed reported experiencing 
challenges adhering to two requirements from VHA's 2016 Directive 
1116(2).

      Climate control monitoring requirement. According to 
officials from 16 VISNs and two VA medical centers, meeting the climate 
control monitoring requirement related to humidity and airflow in 
facility areas where RME is reprocessed and stored is a challenge for 
some, if not all, of their VA medical centers, particularly older VA 
medical centers that lack proper ventilation systems. \13\
---------------------------------------------------------------------------
    \13\ Under the climate control monitoring requirement, airflow 
needs to be carefully controlled in areas where RME is reprocessed and 
stored to minimize movement of air from dirty areas to clean areas 
(e.g., areas where used instruments are brought to be reprocessed and 
areas where unused instruments are stored before usage). Also, humidity 
must be monitored in the areas RME is reprocessed and stored so that 
humidity levels do not exceed certain thresholds.
---------------------------------------------------------------------------
      Reprocessing transportation deadline requirement. 
Officials from 16 VISNs and two VA medical centers reported that 
meeting the reprocessing transportation deadline was challenging for 
their VA medical centers. They said this was particularly challenging 
for VA medical centers that must transport their RME to another 
facility for cleaning, such as community based outpatient clinics in 
rural areas that must transport their RME to their VA medical center's 
SPS department. \14\ Under the requirement, used RME must be 
transported to the location where it will be reprocessed within 4 hours 
of use to prevent bioburden or debris from drying on the instrument and 
causing reprocessing challenges.
---------------------------------------------------------------------------
    \14\ Under the reprocessing deadline requirement, all used RME must 
be transported to the location where it will be reprocessed within 4 
hours (or 12 hours for offsite facilities if a specific pre-cleaning 
spray is used, per a VHA memorandum issued on June 1, 2016).

    In a report we issued in September 2017 examining VA's policy 
management practices, we recommended that VHA establish a mechanism 
through which program offices could systematically obtain feedback from 
VISN and VA medical center officials after the implementation of new 
national policies. \15\ The more recent findings of our August 2018 
report provide further evidence of the need for VA to address that 
recommendation.
---------------------------------------------------------------------------
    \15\ VHA agreed with our recommendation; however, as of March 2018 
VHA had not implemented it. GAO, VA Health Care: Additional Actions 
Could Further Improve Policy Management, GAO 17 748 (Washington, D.C.: 
Sept. 22, 2017).
---------------------------------------------------------------------------
    Regarding the challenges VA medical centers face in meeting SPS 
workforce needs, almost all of the 18 VISN officials and officials from 
the three selected VA medical centers we interviewed reported 
experiencing challenges related to lengthy hiring timeframes, the need 
for consistent overtime practices, and limited pay and opportunities 
for professional growth. According to these officials, such challenges 
make it difficult for SPS programs to maintain sufficient staffing 
levels.

      Lengthy hiring timeframes. Officials from 14 VISNs and 
three VA medical centers reported that the lengthy hiring process for 
SPS staff creates challenges in maintaining a sufficient SPS workforce. 
For example, officials from one VISN estimated that it can take 3 to 4 
months on average to hire a new SPS staff member.
      Need for overtime. Officials from 16 VISNs and two VA 
medical centers reported that needing SPS staff to work overtime is a 
challenge. Further, officials from one VISN told us that their VA 
medical center had used overtime to meet increased workload demands 
required to implement VHA's RME policies. One official we interviewed 
noted that the overtime has led to dissatisfaction and retention issues 
among SPS staff.
      Limited pay and opportunities for professional growth. 
Officials identified limited pay and lack of opportunities for 
professional growth as the biggest SPS workforce challenge. \16\ These 
officials stated that the relatively low maximum allowable pay 
discourages staff from accepting or staying in SPS positions and the 
current pay grade does not create a career path for SPS medical supply 
technicians to grow within the SPS department. VHA officials told us 
that a proposed increase in the pay grade for SPS staff has been 
drafted; however, the officials do not know when or if it will be made 
effective. Further, according to VHA officials with knowledge of the 
proposed changes, the changes could still be insufficient to recruit 
and retain SPS staff with the necessary skills and experience.
---------------------------------------------------------------------------
    \16\ In our review, officials from all 18 VISNs and three VA 
medical centers reported experiencing challenges with relatively low 
pay. Officials from 14 VISNs and 1 VA medical center reported 
experiencing challenges with professional growth for SPS staff.

    While VHA is aware of these workforce challenges cited by VISN and 
VA medical center officials, it has not studied SPS staffing issues at 
VA medical centers. VHA officials told us that VHA is considering 
studying its SPS workforce. However, the agency has not announced a 
plan or a timeframe for doing so. Until the study is conducted and 
actions are taken based on the study, as appropriate, VHA will not have 
addressed a potential risk to its SPS programs. This is inconsistent 
with standards for internal control in the federal government for risk 
assessment, which state that management should identify, analyze, and 
respond to risks related to achieving defined objectives. \17\ 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.
---------------------------------------------------------------------------
    \17\ See GAO 14 704G.
---------------------------------------------------------------------------
    Based on our findings, we recommended in our August 2018 report 
that VA assess its SPS workforce needs, and take action based on this 
assessment, as appropriate. VA concurred with this recommendation and 
said that VHA has an interdisciplinary work group that has identified 
actions it can take to address SPS workforce needs.
    Chairman Bergman, Ranking Member Kuster, and Members of the 
Subcommittee, this concludes my statement. I would be pleased to 
respond to any questions that you may have at this time.

GAO Contact and Staff Acknowledgments

    For further information about this statement, please contact Sharon 
Silas at (202) 512-7114 or [email protected]. Contact points for our 
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above, key contributors to this statement were Karin Wallestad 
(Assistant Director), Teresa Tam (Analyst-in-Charge), Kenisha Cantrell, 
Krister Friday, and Michael Zose.

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Washington, DC 20548

                                 
           Prepared Statement of JOHN D. DAIGH, JR., MD, CPA
    Mr. Chairman, Ranking Member Kuster, and members of the 
Subcommittee, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG's) oversight of VA facilities' Sterile 
Processing Services (SPS) and how VA has responded to our 
recommendations. High-quality sterile processing of reusable 
instruments and equipment is critical to patient safety, yet has 
traditionally been difficult for VA to consistently deliver.

BACKGROUND

    Over the past decade, the OIG has issued significant findings and 
recommendations for corrective action related to sterile processing of 
Reusable Medical Equipment (RME). As highlighted in our March 2018 
report on Critical Deficiencies at the Washington, DC VA Medical Center 
(DC Report), there is still cause for concern regarding the management 
of sterile processing operations and VA's ability to ensure consistent 
compliance with quality standards across its medical facilities. The DC 
Report underscores the ongoing need for VA leaders to respond 
aggressively to reports of management failures within individual 
facilities' Sterile Processing Services and other hospital business 
lines that have a direct impact on patient care. Just as consequential, 
VA must take appropriate proactive steps to ensure these processes are 
properly carried out by adequately trained professionals whose work and 
qualifications are being consistently and carefully monitored.
    Ensuring that Sterile Processing Services are functioning properly 
is of critical importance. To advance both patient safety and sound 
financial management, RME must be reprocessed by individuals with the 
required competencies, according to manufacturers' instructions and 
related procedures, and then inventoried, secured, and maintained in 
clean conditions. Proper sterile processing and storage of RME is 
essential to preventing contamination and patient infections, as well 
as product deterioration. The OIG has reported instances in which 
improper sterile processing has resulted in canceled surgeries and 
delays in procedures, inefficiency due to repeat processing of RME, and 
increased risk of patient harm.

OIG OVERSIGHT

    The OIG has provided oversight of Sterile Processing Services 
primarily through two types of inspections or reviews. First, we have 
conducted reviews and published individual reports in response to 
specific allegations of problems with sterile processing of RME, 
usually through complaints received by the OIG Hotline. The second line 
of reporting results from our Comprehensive Healthcare Inspections 
Program (CHIP) in which OIG staff examine sterile processing as part of 
recurring routine inspections of VA medical centers (VAMCs).
    As an example of specific allegations, in 2009, OIG reported on the 
Veterans Health Administration's (VHA) difficulty reprocessing 
endoscopes and concluded that, \1\
---------------------------------------------------------------------------
    \1\ Healthcare Inspection Use and Reprocessing of Flexible 
Fiberoptic Endoscopes at VA Medical Facilities, June 16, 2009.

    ``Facilities have not complied with management directives to ensure 
compliance with reprocessing of endoscopes, resulting in a risk of 
infectious disease to veterans. Reprocessing of endoscopes requires a 
standardized, monitored approach to ensure that these instruments are 
safe for use in patient care. The failure of medical facilities to 
comply on such a large scale with repeated alerts and directives 
suggests fundamental defects in organizational structure.''
    In 2010, we reported on similar issues in Puerto Rico where RME was 
not properly sent for reprocessing. \2\ In addition to the RME issues 
that involve surgical service, the OIG has reported on instrument 
reprocessing issues with dental equipment, which is not directly under 
the control of Sterile Processing Services in all facilities. \3\
---------------------------------------------------------------------------
    \2\ Healthcare Inspection Patient Safety Issues VA Caribbean 
Healthcare System San Juan, Puerto Rico, March 6, 2010.
    \3\ Healthcare Inspection Reprocessing of Dental Instruments John 
Cochran Division of the St. Louis VA Medical Center St. Louis, 
Missouri, March 7, 2011; Oversight Review of Dental Clinic Issues 
Dayton VA Medical Center Dayton, Ohio, April 25, 2011; Healthcare 
Inspection-Review of Improper Dental Infection Control Practices and 
Administrative Action, Tomah VA Medical Center, Tomah, Wisconsin, 
September 7, 2017.
---------------------------------------------------------------------------
    As for CHIP reviews, previously known as the Combined Assessment 
Program (CAP) reviews, the OIG performs recurring inspections of all 
VAMCs in which we assess a wide range of hospital functions and 
performance areas. In the 2009-2010 CAP cycle, sterile processing was 
one of the areas reviewed. In a 2010 roll-up report of data and trends 
from completed CAP reviews, the OIG provided recommendations for 
system-wide improvements to Sterile Processing Services. The OIG 
reported the following:
    ``We identified six areas that needed improvement. We recommended 
that the Under Secretary for Health, in conjunction with Veterans 
Integrated Service Network and facility senior managers, ensures that: 
(1) standard operating procedures (SOPs) be current, consistent with 
manufacturers' instructions, and located within the reprocessing areas; 
(2) employees consistently follow SOPs, supervisors monitor compliance, 
and annual training and competency assessments be completed and 
documented; (3) flash sterilization be used only in emergent 
situations, supervisors monitor compliance, and managers assess and 
document annual competencies for employees who perform flash 
sterilization; (4) appropriate personal protective equipment be donned 
before entering and worn in decontamination areas; (5) ventilation 
systems be inspected and filters changed quarterly in all reprocessing 
areas and that temperature and humidity levels be monitored and 
maintained within acceptable ranges in sterile storage areas; and (6) 
processes for consistent internal oversight of RME activities be 
established to ensure senior management involvement.''
    Altogether, the above OIG reports highlighted the need for proper 
equipment sterilization throughout each medical center. They also 
demonstrated that VA did not employ business practice standards that 
were consistently enforced in all areas of the medical centers that use 
and reprocess medical equipment.

VA RESPONSE

    In VA's response to our findings, there was recognition that beyond 
the specific issues we identified, there were important organizational 
challenges that needed to be addressed to ensure consistent and proper 
reprocessing of surgical equipment. In their response to our 2009 
endoscopy report, VA stated, \4\
---------------------------------------------------------------------------
    \4\ Healthcare Inspection Follow-Up Colonoscope Reprocessing at VA 
Medical Facilities, September 17, 2009.

    ``Additional components that VHA will specifically evaluate and 
address include organizational structures and systems in order to 
ensure reusable medical equipment is reprocessed according to 
manufacturers' instructions with high reliability, and to document 
facility compliance with recommended standard operating procedures as 
well as with implementation of appropriate responses to alerts and 
directives impacting reprocessing. VHA will take several measures to 
---------------------------------------------------------------------------
ensure this:

    A. VHA will implement systems to ensure that all individuals 
engaged in reprocessing reusable medical equipment will have device-
specific competencies documented and demonstrated at a minimum on an 
annual basis.

    B. VHA will implement measures to ensure that device and procedure 
specific standard operating procedures (SOPs) are uniformly available, 
are updated as required, and are reviewed at least annually.

    C. And ensure that robust quality control is implemented and 
appropriately documented in all VHA facilities where reprocessing 
occurs.

    D. VHA will standardize equipment at the facility level where ever 
possible to ensure uniformity in the setup, use and reprocessing of 
equipment.

    E. VHA will negotiate national contracts to ensure standardization 
of equipment and leverage its ability to maximize added value from the 
vendors, including support of maintenance, repair and training.''

    VA also took the significant step of reorganizing the management of 
Sterile Processing Services to fall under nursing staff supervision.
    The progress that VA made was seen in the 2016 CAP review cycle, 
when the OIG again included a section focused on sterile processing. 
The OIG team reviewed facility policies, procedures and guidelines for 
(1) reprocessing RME, (2) training and demonstrating competencies for 
employees who reprocess RME, and (3) quality control measures for 
testing bioburdens in endoscopes. In addition, the review tested 
whether the manufacturer's instructions for proper sterile processing, 
local SOPs, and quality control measures were in place for the 
reprocessing of selected endoscopes at central and peripheral areas 
within the VAMC. The majority of medical centers reviewed during the 
2016 CAP inspection cycle scored above 90 percent in the sterile 
processing section. VA also demonstrated that policies were in place to 
review the quality of reprocessing of individual scopes if quality 
assurance testing indicated the scope was not reprocessed correctly. 
\5\
---------------------------------------------------------------------------
    \5\ Data pulled from individual CAP reviews from Fiscal Year 2016 
cycle.
---------------------------------------------------------------------------
    The results of the 2016 reviews indicate that many facility leaders 
were focused on ensuring sterile processing of RME was being correctly 
performed and demonstrated marked improvement from previous reviews. In 
support of these findings, the OIG is aware of numerous instances at 
VAMCs where sterile processing errors were made and the proper 
corrective actions were taken or the operating room was closed until 
further evaluation of instrument status could be obtained. \6\ Although 
shutdowns should clearly be avoided, it is important to be supportive 
of facilities that recognize a problem and take proper measures to 
ensure patient safety. In recent years, the OIG has engaged in numerous 
informal discussions with VA leaders when there have been reports or 
evidence of a possible sterilization problem at a medical center. In 
these instances, we have found overall that appropriate prompt actions 
have been taken by VA to ensure sterile processing errors do not result 
in more serious adverse outcomes for patients.
---------------------------------------------------------------------------
    \6\ Healthcare Inspection - Delayed Access to Primary Care, 
Contaminated Reusable Medical Equipment, and Follow-Up of Registered 
Nurse Staffing Concerns, Southern Arizona VA Health Care System, 
Tucson, Arizona, September 26, 2017.

---------------------------------------------------------------------------
CRITICAL DEFICIENCIES AT THE WASHINGTON DC VAMC

    VA's improvements in sterile processing make the findings in our 
report, Critical Deficiencies at the Washington, DC VA Medical Center, 
all the more startling. \7\ The OIG detailed multiple and extensive 
deficiencies within the Washington, DC VAMC's Sterile Processing 
Services that impeded healthcare providers' efforts to deliver quality 
patient care, included the following:
---------------------------------------------------------------------------
    \7\ Critical Deficiencies at the Washington DC VAMC, March 7, 2018.

      Problems in the sterile processing of instruments, such 
as discolored or broken instruments reaching clinical areas; incomplete 
surgical trays in the operating room; improper tracking and 
reprocessing procedures for loaner instruments; missing or expired 
sterile processing supplies; failure to follow reprocessing 
instructions; and not separating clean and dirty items in satellite 
reprocessing areas
      An ineffective quality assurance program to ensure that 
instruments were cleaned appropriately prior to being returned to a 
clinical area
      No reliable way for ensuring that instrument sets sent 
back to clinical areas were complete and ready for use
      Some clean/sterile storerooms did not meet selected 
infection prevention criteria and/or selected cleanliness criteria
      Multiple problems with competencies for the technicians 
responsible for sterilizing instruments and equipment, including 
expired or undated competencies, lack of documentation regarding 
required training, and competencies not consistently updated to keep 
pace with manufacturer's issuance of instructions

    DC VAMC personnel often attributed deficiencies in Sterile 
Processing Services to chronic understaffing. The OIG confirmed that 
Sterile Processing Services had experienced historically high vacancy 
rates. A number of factors contributed to these rates, including a 
failure to maintain accurate data on the number of authorized positions 
throughout the medical center; the Resource Management Committee not 
performing its duties in accordance with policy; and HR not completing 
hiring actions appropriately.
    The OIG also determined that high turnover rates in HR leadership 
may have contributed to the failure to resolve staffing issues. VA has 
reported progress in hiring, but vacancy rates for Sterile Processing 
Services staff are still high at the medical center. During our DC 
review, VHA leaders reported that they have experienced difficulties in 
recruiting qualified SPS staff nationwide, in part because of a 
relatively low salary structure. The fact that many VAMCs continue to 
provide high-quality Sterile Processing Services suggests that staffing 
issues alone do not necessarily result in deficiencies like those found 
at the DC VAMC.
    Additionally, it is important to note that the problems identified 
in the DC Report were not new. It is clear that information and 
documentation outlining some, if not most, of the sterile processing 
failings in the medical center reached responsible officials as early 
as 2013. That includes the DC VAMC leadership, the Veteran Integrated 
Service Network (VISN) 5 leaders, and VHA Central Office. \8\ However, 
actions taken by leadership did not effectively remediate the 
conditions. Overall, the DC Report highlights the negative impacts 
resulting from a lack of leadership attention placed upon key business 
practices and logistics.
---------------------------------------------------------------------------
    \8\ VISN 5, VA Capitol Health Care Network, has managerial 
oversight responsibility over the Washington, DC VAMC.
---------------------------------------------------------------------------
    During the DC VAMC review process, we noted some real-time 
improvements in the cleanliness of storage rooms. The medical center 
had entered into a contract with a commercial cleaning service in June 
2017 to supplement the medical center Environmental Management Services 
staff. Additionally, as of September 2017, the Acting Human Resources 
Director reported to the OIG that 138 of 147 authorized EMS positions 
were filled. We have conducted a follow-up review of the DC VAMC and 
will be reporting our findings in the near future.

CONCLUSION

    Although the findings and recommendations in the DC Report focus on 
issues in sterile processing at that facility, VHA leadership at all 
levels could use the findings as a checklist to ensure properly 
functioning Sterile Processing Services at all VAMCs. The DC Report is 
about the breakdown of systems and leadership at multiple levels that 
other VAMCs should be cautioned to avoid or quickly redress.
    The OIG's ongoing oversight and communication with VA leaders 
indicates that some individual facilities have made important strides 
in how sterile processing is managed. Yet reports like the one on the 
DC VAMC makes clear that these problems still resurface in individual 
facilities, due in part to both the complexity of the processes and the 
lack of adequate internal controls to provide assurance that sterile 
processing is meeting essential quality standards. Staffing may also be 
an ongoing challenge in addressing sterile processing problems. 
Finally, VA must have effective leaders who understand the critical 
importance of close oversight of nonclinical services that affect 
patient care within medical centers to continue its improvement 
efforts. Leaders at all VA facilities must take appropriate proactive 
steps and have reactive measures in place to address sterile processing 
concerns. Failure to do so puts at risk the safety and quality of care 
delivered to veterans.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or other members of the Subcommittee may have.

                                 [all]