Department of Veterans Affairs
 

Office of Inspector General
 

Combined Assessment Program
 

Summary Report
 

Evaluation of
 

Infection Prevention Practices in
 

Veterans Health Administration Facilities
 

Report No. 11-03361-274 September 13, 2011 

VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections evaluated selected 

infection prevention (IP) practices in Veterans Health Administration facilities. The 

purposes of the evaluation were to determine whether facilities complied with required IP 

practices in patient care units/areas, trained employees on the Occupational Safety and 

Health Administration Bloodborne Pathogens Rule, and performed N95 respirator fit 

testing. 

As part of the environment of care review, inspectors evaluated selected IP practices at 

69 facilities during Combined Assessment Program reviews conducted from 

January 1, 2010, through March 31, 2011. 

Veterans Health Administration facilities recognized the importance of maintaining 

consistent IP practices to ensure veterans’ safety and reduce the incidence of health 

care-associated infections. We noted many consistent and effective IP practices during 

our inspections. We identified five areas where compliance with selected IP 

requirements needed to improve. We recommended that the Under Secretary for Health, 

in conjunction with Veterans Integrated Service Network and facility senior managers, 

ensures that: 

 Corrective actions are initiated when hand hygiene performance falls below 

established thresholds. 

 Ultraviolet germicidal irradiation fixtures are turned on and functional. 

 Negative pressure is monitored and within acceptable levels in occupied airborne 

infection isolation rooms and that results are documented. 

 Employees with occupational exposure risk complete annual Occupational Safety and 

Health Administration Bloodborne Pathogens Rule training and that compliance is 

monitored. 

 Designated employees complete annual N95 respirator fit testing and that compliance 

is monitored. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Under Secretary for Health (10) 

SUBJECT: Combined 

Infection 

Facilities 

Assessment Program 

Prevention Practices in 

Summary R

Veterans 

eport 

Health 

– Evaluation of 

Administration 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections evaluated 

selected infection prevention (IP) practices in Veterans Health Administration (VHA) 

facilities. The purposes of the evaluation were to determine whether facilities complied 

with required IP practices in patient care units/areas, trained employees on the 

Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Rule, 

and performed N95 respirator fit testing. 

Background 

Any health care facility, regardless of its size or location, faces vulnerabilities in the 

environment, such as infections, cleanliness, and safety hazards. The goal is to reduce 

and control environmental hazards and risks and maintain safe conditions for patients, 

visitors, and staff. The physical environment of a health care facility must not only be 

functional but should also promote healing. Although the majority of health 

care-associated infections involve clinical factors, a significant number of deaths have 

been linked to environmental failures. VHA requires managers to conduct environment 

of care (EOC) inspection rounds and resolve EOC issues in a timely manner. VHA 

facilities’ EOC and IP programs must fully meet all VHA, OSHA, National Fire 

Protection Association, and Joint Commission standards. During VA OIG Combined 

Assessment Program EOC reviews, inspectors have assessed IP practices and determined 

facility compliance with applicable standards and regulations for many years. Inspectors 

have presented identified IP deficiencies to facility managers who then developed 

improvement strategies and tracked deficiencies through to resolution. 

All 69 facilities in our review performed the required annual IP risk assessments, and 

most implemented actions to address high-risk areas and followed up on actions 

implemented. Nearly all facilities were fully compliant with IP expectations, including 

VA Office of Inspector General 1 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

securing and not overfilling sharps containers, separating clean and dirty supplies, and 

ensuring staff were knowledgeable regarding precautions for patients in isolation. 

From October 2010–March 2011, we assessed selected IP practices in 62 Radiology 

Service areas at 24 facilities. Nearly all facilities were fully compliant with IP 

expectations, including having readily available hand hygiene products, using clean 

gloves, and effectively cleaning equipment between patients. 

From January–September 2010, we assessed selected IP practices in hemodialysis 

units/functions at 30 facilities. Nearly all facilities were fully compliant with IP 

practices, including having and using personal protective equipment, consistently 

practicing good hand hygiene, and using single-dose and multi-dose medication vials for 

only one patient. 

Scope and Methodology 

We performed this review at 69 VA medical facilities during Combined Assessment 

Program reviews conducted from January 1, 2010, through March 31, 2011. The 

facilities reviewed represented a mix of size, affiliation, geographic location, and 

Veterans Integrated Service Networks (VISNs). We generated an individual Combined 

Assessment Program report for each facility. For this report, we analyzed and 

summarized the data from the individual facility Combined Assessment Program 

reviews. 

We interviewed selected program managers and reviewed documents, including facility 

self-assessments and training records. Additionally, we conducted physical inspections 

of selected patient care units. Some of the areas reviewed did not apply to all VHA 

facilities because of differences in functions or frequencies of occurrences; therefore, 

denominators differ in our reported results. We used 90 percent as the general level of 

expectation for performance in the areas discussed below. 

Inspectors conducted the reviews in accordance with Quality Standards for Inspection 

and Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results 

Issue 1: IP Practices in Patient Care Units/Areas 

From January–September 2010, we assessed selected IP practices during EOC 

inspections at 45 facilities and identified the following opportunities for improvement. 

VA Office of Inspector General 2 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

The Joint Commission requires facilities to set goals to improve hand hygiene 

compliance and to initiate corrective actions when established goals are not met.1 

Facilities may measure compliance by monitoring the use of hand hygiene products or by 

observing staff providing patient care. We reviewed facilities’ hand hygiene data and 

determined that five facilities (11 percent) did not initiate corrective actions when 

warranted. 

Facilities may use ultraviolet germicidal irradiation (UVGI) fixtures as an air cleaning 

method in high-risk areas such as patient rooms, emergency rooms, and public waiting 

areas. Of the 42 patient care areas inspected that used UVGI fixtures, 6 (14 percent) had 

fixtures that were not turned on and/or functional. 

Patients with suspected or diagnosed infections such as pulmonary tuberculosis must be 

isolated in negative air pressure rooms to prevent the spread of the airborne pathogens. 

The negative air pressure ensures that the air is exhausted to the outside of the building 

from these types of rooms instead of being recirculated into other rooms or hallways. 

The Centers for Disease Control and Prevention recommends that staff monitor occupied 

airborne infection isolation (AII) rooms daily for proper negative air pressure and record 

the results. We inspected 116 patient care units that had at least one AII room. 

Eleven (9 percent) of the patient care units did not have negative pressure logs. Of the 

105 units with logs, negative pressure was not documented on 13 (12 percent) of the 

units. 

We recommended that: 

 Corrective actions are initiated when hand hygiene performance falls below 

established thresholds. 

 UVGI fixtures are turned on and functional. 

 Negative pressure is monitored and within acceptable levels in occupied AII rooms 

and that results are documented. 

Issue 2: OSHA Bloodborne Pathogens Rule Training 

OSHA requires facilities to ensure that employees with occupational exposure risk 

complete annual Bloodborne Pathogens Rule training. Training topics include an 

explanation of the epidemiology and symptoms of bloodborne diseases, an explanation of 

the modes of transmission of infection, and information on the hepatitis B vaccine.2 We 

reviewed clinical and housekeeping employees’ training records for evidence of annual 

training. We found that 16 (23 percent) of the 69 facilities were not in compliance. 

1 The Joint Commission, “Hospital Accreditation Program, 2010 Chapter: National Patient Safety Goals,” National
 

Patient Safety Goal 07.01.01, performance elements1–3.

2 OSHA 29CFR1910.1030(g)(2)(i-ix).
 

VA Office of Inspector General 3 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

We recommended that employees with occupational exposure risk complete annual 

OSHA Bloodborne Pathogens Rule training and that supervisors monitor compliance. 

Issue 3: N95 Respirator Fit Testing 

N95 respirators provide a higher level of respiratory protection than surgical grade masks 

for health care workers caring for patients with certain airborne infections. OSHA 

requires facilities to ensure that designated employees are tested for proper respirator fit 

prior to initial use and at least annually thereafter.3 Sixty-six of the 69 facilities in our 

review required N95 respirator use. We reviewed fit testing records of employees who 

worked in emergency rooms, medical units, radiology, bronchoscopy, and community 

living centers and were designated to use N95 respirators. Table 1 below shows 

non-compliance for employee fit testing by work area. 

Table 1 

Percentage of Designated Employees Who Were not Fit Tested Annually 

Emergency Rooms 48% 

Medical Units 50% 

Radiology 50% 

Bronchoscopy 57% 

Community Living Centers 63% 

We recommended that designated employees complete annual N95 respirator fit testing 

and that compliance is monitored. 

Conclusions 

VHA facilities demonstrated many consistent and effective IP practices. However, 

compliance with applicable IP requirements needs to improve in the areas of hand 

hygiene corrective actions, UVGI fixture usage, AII room monitoring and 

documentation, OSHA Bloodborne Pathogens Rule training, and N95 respirator fit 

testing. 

Recommendations 

Recommendation 1. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that corrective actions are 

initiated when hand hygiene performance falls below established thresholds. 

3 OSHA 29CFR1910.134(f)(2). 

VA Office of Inspector General 4 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

Recommendation 2. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that UVGI fixtures are 

turned on and functional. 

Recommendation 3. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that negative pressure is 

monitored and within acceptable levels in occupied AII rooms and that results are 

documented. 

Recommendation 4. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that employees with 

occupational exposure risk complete annual OSHA Bloodborne Pathogens Rule training 

and that compliance is monitored. 

Recommendation 5. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that designated employees 

complete annual N95 respirator fit testing and that compliance is monitored. 

Comments 

The Under Secretary for Health concurred with the findings and recommendations. The 

implementation plan is acceptable, and we will follow up until all actions are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 5 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 2, 2011 

From: Under Secretary for Health (10) 

Subject: OIG Combined Assessment Program Summary 

Report – Evaluation of Infection Prevention Practices in 

Veterans Health Administration Facilities (VAIQ 7130599) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and concur with all five of the report’s 

recommendations. Attached is the Veterans Health Administration’s 

(VHA) corrective action plan for the report’s recommendations. 

2. Thank you for the opportunity to review the draft report. If you have 

any questions, please contact Linda H. Lutes, Director, Management 

Review Service (10A4A4) at (202) 461-7014. 

(original signed by:) 

Robert A. Petzel, M.D. 

Attachment 

VA Office of Inspector General 6 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

VETERANS HEALTH ADMINISTRATION (VHA)
 

Action Plan
 

OIG Combined Assessment Program Summary Report: Evaluation of 

Infection Prevention Practices in Veterans Health Administration 

Facilities (VAIQ 7130599) 

Date of Draft Report: June 28, 2011 

Recommendations/ Status Completion 

Actions Date 

Recommendation 1. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

corrective actions are initiated when hand hygiene performance falls below 

established thresholds. 

VHA Comments 

Concur 

VHA Office of the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) and the Office of the Deputy Under Secretary for 

Health for Policy and Services (DUSHPS), Office of Public Health, are 

conducting a survey to explore what hand hygiene tools are being used and 

how these tools are being used. Based on the results of the survey, the 

Infection Don’t Pass It On (IDPIO) workgroup will create a toolkit and the 

DUSHOM will distribute the toolkit to facilities for implementation. 

In process	 Hand washing Tool 

Survey will be 

completed 

September 30, 2011 

Toolkit to be 

assembled by 

January 31, 2012 

The DUSHOM will schedule a data call to each facility. The Hospital 

Epidemiology/Infection Control staff will complete the data which will be 

used to assess how facilities are meeting the intent of the current hand 

VA Office of Inspector General 7 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

washing directive and how they modify practices when hand washing 

compliance is inadequate. 

In process Hand washing 

Assessment Survey 

to go out by 

December 30, 2011 

A meeting between field quality managers/infection control staff and VHA 

Central Office program office staff from DUSHOM Clinical Operations 

and staff from DUSHPS Infectious Disease Program Office, Patient Care 

Services and Occupational Health/Center for Occupational Health Infection 

Control, Office of Public Health, will be held to evaluate the effectiveness 

of: 

•	 recent hand washing pilot programs, 

•	 lessons from the National Center for Patient Safety’s (NCPS) 

Six-Sigma hand-washing project, 

•	 IDPIO toolkit, and 

•	 potential innovative evaluation methods. 

The DUSHOM and DUSHPS will use results from this meeting to develop 

pilot projects to compare and implement hand washing interventions and 

assessments. The group will also evaluate strategies on developing 

measurement techniques to support national reporting through the quality 

indicators Web site. 

In process Meeting to be 

Scheduled by 

October 31, 2011 

Recommendation 2. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

UVGI fixtures are turned on and functional. 

VHA Comments 

Concur 

The DUSHOM and the DUSHPS, Office of Public Health, will collaborate 

to determine the reason for non use of ultraviolet germicidal irradiation 

(UVGI) fixtures and whether non-use of UVGI is a reasonable strategy at 

VHA facilities. A report including recommendations for appropriate 

VA Office of Inspector General 8 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

actions will be completed with an action plan and timeline to implement 

any recommendations by December 31, 2011. 

In process Report to be 

completed by 

December 31, 2011 

Recommendation 3. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

negative pressure is monitored and within acceptable levels in occupied AII 

rooms and that results are documented. 

VHA Comments 

Concur 

The DUSHOM and DUSHPS, Office of Public Health, have designed a 

survey of Airborne Infection Isolation (AII) rooms to ensure that negative 

pressure is monitored. The survey will address design, construction, and 

maintenance practices of AII rooms in facilities. The DUSHOM and 

DUSHPS will analyze the information from the survey, consider current 

standards and needs, and take appropriate corrective actions. The 

DUSHOM will issue an Information Letter with the results and 

recommendations. 

In process Pilot of Survey by 

September 30, 2011 

Full Survey 

completed by 

November 30, 2011 

Analysis and 

identification of 

issues with action 

plan and timelines 

developed NLT 

December 30, 2011 

Intervention, 

April 30 2012 

Recommendation 4. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

VA Office of Inspector General 9 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

employees with occupational exposure risk complete annual OSHA 

Bloodborne Pathogens Rule training and that compliance is monitored. 

VHA Comments 

Concur 

The DUSHPS and the DUSHOM will collaboratively review the 

Occupational Safety and Health Administration (OSHA) standard for 

completion of annual bloodborne pathogens Rule training as well as 

existing information provided to VHA field facilities about the 

requirement; update existing information to re-emphasize the need to 

comply with the OSHA standard; and develop requirements for monitoring 

and compliance in field facilities. To operationalize this in the field, 

appropriate information will be developed to outline requirements for 

facilities to have appropriate staff complete the testing and ensure facility 

leadership monitor that the testing is completed. 

In process December 31, 2011 

Recommendation 5. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

designated employees complete annual N95 respirator fit testing and that 

compliance is monitored. 

VHA Comments 

Concur 

The DUSHOM will issue a memorandum to the field re-emphasizing the 

compliance with N95 fit testing for designated employees. This 

communication will address the need to ensure compliance is monitored. 

In process December 31, 2011 

VA Office of Inspector General 10 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors	 Annette Acosta, RN 

Bruce Barnes 

Lisa Barnes, MSW 

Gail Bozzelli, RN 

Shirley Carlile, BA 

Paula Chapman, CTRS 

Audrey Collins-Mack, RN 

Melanie Cool, LD 

Kathy Gudgell, RN, JD 

Stephanie Hensel, RN, JD 

Deborah Howard, RN 

Gayle Karamanos, PA 

Frank Keslof, MHA 

Cathleen King, RN 

Jeanne Martin, PharmD 

Claire McDonald, MPA 

Judy Montano, MS 

Alice Morales-Rullan, RN 

Sami O’Neill, MA 

Jennifer Reed, RN 

Mary Rees, MPA 

Clarissa Reynolds, MBA 

James Seitz, RN 

Kathleen Shimoda, RN 

Karen Sutton, BS 

Ann Ver Linden, RN 

Marilyn Walls, RN 

VA Office of Inspector General 11 
Evaluation of Infection Prevention Practices in Veterans Health Administration Facilities 

Appendix C 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

National Center for Patient Safety 

Office of General Counsel 

Office of Medical Inspector 

Veterans Integrated Service Network Directors (1–23) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 12