- The VA recently removed its medical center director from his position and temporarily reassigned him to administrative duties after the Office of Inspector General (OIG) reported several patient safety concerns stemming from healthcare supply chain management inadequacies.
Charles Faselis, MD, will be the acting Medical Center Director while the VA reviews the OIG findings from March 2017.
“VA’s top priority is to ensure that no patient has been harmed,” the federal department stated. “If appropriate, additional disciplinary actions will be taken in accordance with the law.”
Based on interviews, documents, and physical inspections of satellite storage areas in March 2017, the OIG reported the following healthcare supply chain management issues:
• No evidence of an effective inventory management system for identifying the availability of medical equipment and supplies for patient care
• No evidence of an effective system for ensuring medical equipment and supplies that were recalled for patient safety concerns were not used on patients
• 18 of the 25 sterile satellite storage areas were dirty
• Over $150 million in healthcare supplies had not been inventoried in the past year
• The lease for a large warehouse of non-inventoried equipment, materials, and supplies was set to expire on April 30, 2017, but the VA had no plan to move warehouse contents
• Several open senior staff positions made healthcare supply chain management remediations difficult to implement
While the OIG did not find any adverse patient outcomes resulting from the VA’s supply chain management inefficiencies, the federal watchdog determined that the challenges did put patient safety at risk.
“The Medical Center placed patients at unnecessary risk by failing to ensure that appropriate medical supplies and equipment were available to providers when needed; that recalled supplies or equipment were not used on patients; and that sterile supplies were stored appropriately,” the OIG wrote.
The federal watchdog also found that the VA was aware of healthcare supply chain management inadequacies prior to the OIG investigation. For example, the Medical Center recorded 194 patient safety reports relating to medical supplies and equipment unavailability since Jan. 1, 2014.
The VA also did not renew its contract with a healthcare supply chain management vendor Catamaran in January 2016 for an inventory management system. The federal department reported that the Medical Center still did not have an approved inventory management system in January 2017.
At that time, the VA’s Procurement and Logistics Office, Policy, Assistance, and Quality group also uncovered stock outages and infection control issues in several clinical supply areas.
To improve healthcare supply chain management policies, the OIG recommended the following immediate changes for the VA’s Under Secretary for Health:
• Ensure that necessary healthcare supplies and equipment are available in patient care cases at the Medical Center
• Install an effective inventory management system through the Medical Center
• Confirm that current Medical Center stock does not contain recalled supplies or equipment
• Guarantee the environmental integrity of the sterile satellite storage areas complies with VA policy
• Develop an inventory and establish accountability over healthcare supplies in the off-site warehouse
• Confirm that the Medical Center and Veterans Integrated Service Network create an orderly movement plan for supplies from the warehouses that minimizes financial losses
• Deploy more logistics staff with Generic Inventory Package experience to the Medical Center until evidence shows existing staff can handle the inventory management system
• Hire permanent Medical Center positions, including Associate VA Medical Center Director, Nurse Executive, Logistics Chief, Assistant Logistics Chief, and supply technicians
The VA already implemented several healthcare supply chain management improvements, such as creating an incident command center and temporarily assigning an additional logistics chief, supply technicians, and Veterans Integrated Service Network staff to the Medical Center.
However, the OIG stated that the actions were “short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified.”
In response, the VA plans to replace the Medical Center Director while the OIG conducts a review of the healthcare supply chain management process during March and April 2017.