Department of Veterans Affairs
	

Office of Inspector General
	

Combined Assessment Program
 

Summary Report
 

Evaluation of
 

Reusable Medical Equipment Practices in
 

Veterans Health Administration Facilities
 

Report No. 10-00135-121 March 14, 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 Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

Executive Summary
	

The VA Office of Inspector General, Office of Healthcare Inspections completed an

evaluation of Veterans Health Administration (VHA) facilities’ reusable medical

equipment (RME) practices. The purposes of the evaluation were to determine whether

facilities: (1) complied with local and selected VHA standards for RME sterilization and

high-level disinfection, (2) provided and documented annual training for employees who

perform RME reprocessing activities, and (3) assessed and documented annual

competencies for employees who perform RME reprocessing activities.

Inspectors evaluated RME practices at 45 facilities during Combined Assessment

Program reviews conducted from January 1 through September 30, 2010.

VHA facilities recognized the importance of maintaining consistent RME practices to

ensure patients’ safety. Despite VHA’s efforts to fully comply with proper reprocessing

procedures, problems in RME practices continue to occur. It is appropriate at this time to

consider changes to the current management approach to ensure that RME is properly

reprocessed. The identification of technology needs, changes in personnel policies, and

changes in procurement strategies are among the areas that VA should review. We

identified six areas where compliance with RME requirements needs to improve. We

recommended that the Under Secretary for Health, in conjunction with VISN and facility

senior managers, ensures that:

 Standard operating procedures (SOPs) are current, consistent with manufacturers’

instructions, and located within the reprocessing areas.

 Employees consistently follow SOPs, supervisors monitor compliance, and annual

training and competency assessments are completed and documented.

	 Flash sterilization is used only in emergent situations, supervisors monitor

compliance, and managers assess and document annual competencies for employees

who perform flash sterilization.

	 Appropriate personal protective equipment is donned before entering and worn in

decontamination areas.

	 Ventilation systems are inspected and filters are changed quarterly in all reprocessing

areas and that temperature and humidity are monitored and maintained within

acceptable ranges in sterile storage areas.

	 Processes for consistent internal oversight of RME activities are established to ensure

senior management involvement.

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 complete.

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 Assessment Program Summary

Reusable Medical Equipment Practices

Administration Facilities

Report

in

– Evaluation of

Veterans Health

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections (OHI)

evaluated Veterans Health Administration (VHA) facilities’ practices related to the

cleaning, disinfecting, and sterilization of reusable medical equipment (RME). The

purposes of the evaluation were to determine whether facilities: (1) complied with local

and selected VHA standards for RME sterilization and high-level disinfection,

(2) provided and documented annual training for employees who perform RME

reprocessing activities (cleaning, disinfecting, and sterilizing), and (3) assessed and

documented annual competencies for employees who perform RME reprocessing

activities.

Background 

In 2009, the Secretary and the Chairmen of VA oversight committees requested the OIG

to assess the extent of problems related to reprocessing of endoscopic equipment within

VHA facilities. OHI’s inspection1 determined that facilities had not complied with VA

directives regarding the reprocessing of endoscopes, resulting in a risk of infectious

disease to patients. OHI also performed an inspection on colonoscope reprocessing2 to

determine compliance with requirements for standard operating procedures (SOPs) and

employee competency assessment. We determined that all 129 facilities inspected were

compliant with respect to SOPs and that 128 facilities had adequate documentation of

demonstrated competence for reprocessing staff. Because of identified problems with

1 Healthcare Inspection – Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities, Report
 

No. 09-01784-146, June 16, 2009. 2 Healthcare Inspection – Follow-Up Colonoscope Reprocessing at VA Medical Facilities, Report
 

No. 09-02848-218, September 17, 2009.
 

VA Office of Inspector General 1 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

endoscope reprocessing in these reports and because of other OHI inspections identifying

RME issues, we identified a need for further evaluation of reprocessing practices at VHA

medical facilities.

Definitions 

1. RME: Any piece of medical equipment designed by the manufacturer to be reused for

multiple patients.

2. High-level disinfection: A process that eliminates many pathogenic microorganisms,

except bacterial spores, on inanimate objects.

3. Sterilization: A process that destroys or eliminates all forms of microbial life.

4. Decontamination: A process of cleaning and disinfecting medical supplies and

equipment.

5. Flash sterilization: An abbreviated sterilization process to be used during surgical

procedures only in emergent situations, such as when a sterilized instrument is dropped.

6. Personal protective equipment (PPE): Special attire, such as masks, gloves, gowns,

and head and shoe coverings, used to protect employees from exposure to contaminates

during RME cleaning.

7. SOP: A written document containing the specific steps in completing a task. SOPs

are important as a reference for staff who reprocess RME. They should be located in

reprocessing areas for quick reference.

8. Manufacturers’ instructions: Tested and validated instructions developed by the

manufacturer to prepare the device for reuse.

Scope and Methodology 

Inspectors evaluated RME processes at 45 facilities during Combined Assessment

Program (CAP) reviews conducted from January 1 through September 30, 2010. The

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

Veterans Integrated Service Networks (VISNs). We interviewed selected program

managers and reviewed documents, including facility self-assessments, RME-related

policies and SOPs, manufacturers’ instructions, meeting minutes, employee training

records and competency folders, and other documentation related to RME reprocessing.

We also observed employees clean the following RME:

 Bronchoscopes

 Colonoscopes

 Cystoscopes

VA Office of Inspector General 2 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

 Laparoscopes

 Gastroenterology (GI) biopsy forceps

 Biopsy probes

 Dental instruments

 Orthopedic instruments

 Surgical instruments

 Transesophageal echocardiography probes

 Bladder scanners

 Echo ultrasound scanners

 Hemodialysis machines (internal pathways)

Additionally, we conducted inspections of the following RME reprocessing areas:

 Supply, Processing, and Distribution (SPD)

 Operating Room (OR)

 Bronchoscopy

 GI/Endoscopy

 Genitourinary (GU)/Urology

We generated an individual CAP report for each facility. For this report, we analyzed the

data from the individual facility CAP reviews to identify system-wide trends.

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: SOPs 

VHA requires that SOPs be current and consistent with manufacturers’ instructions.3 It is

important that SOPs mirror manufacturers’ instructions because improper reprocessing

could result in transmission of pathogens to patients and affect the functionality of the

RME item. We reviewed 300 SOPs and determined that 279 (93 percent) were current

and that 261 (87 percent) were consistent with manufacturers’ instructions.

VHA also requires that SOPs be located within reprocessing areas for easy reference by

employees.4 Of the 300 SOPs reviewed, 276 (92 percent) were located within

reprocessing areas.

3 VHA Directive 2009-031, Improving Safety in the Use of Reusable Medical Equipment through Standardization of
 

Organizational Structure and Reprocessing Requirements, June 26, 2009.
 4 VHA Directive 2009-031.
 

VA Office of Inspector General 3 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

We recommended that SOPs be current, consistent with manufacturers’ instructions, and

located within the reprocessing areas.

Issue 2: Training and Competency Assessment 

VHA requires that staff be trained and follow RME reprocessing SOPs.5 Additionally,

annual competency assessment is required for all employees who reprocess RME.6

We made 294 observations of the cleaning step of RME reprocessing and determined that

employees followed SOPs in 255 (87 percent) cases. We reviewed training records

associated with each observation and found documented annual training in

241 (82 percent) records. Competencies were completed for 255 (87 percent) of the

294 RME items cleaned.

We recommended that employees consistently follow SOPs, that supervisors monitor

compliance, and that annual training and competency assessments be completed and

documented.

Issue 3: Flash Sterilization 

VA requires that flash sterilization only be used in emergent situations during surgical

procedures, such as when a sterile instrument is dropped yet still needed, or when there

are unplanned emergency procedures requiring the same piece of equipment.7

Flash sterilization was used at 34 of the facilities we reviewed. Of these, 19 facilities

(56 percent) demonstrated appropriate use of flash sterilization. At the remaining

facilities, items that were inappropriately flash sterilized included suction tubes,

instrument sets, and forceps.

Employees who perform flash sterilization must have an annual competency assessment

for this activity. We reviewed 180 competency folders of employees who performed

flash sterilization and found that 147 (82 percent) had documented annual competency

assessments.

We recommended that VHA ensure that flash sterilization is used only in emergent

situations, that supervisors monitor compliance, and that managers assess and document

annual competencies for employees who perform flash sterilization.

5 VHA Directive 2009-031.
 6 VHA Directive 2009-004, Use and Reprocessing of Reusable Medical Equipment (RME) in Veterans Health
 

Administration Facilities, February 9, 2009.
 7 VA Handbook 7176, Supply, Processing and Distribution (SPD) Operational Requirements, August 16, 2002.
 

VA Office of Inspector General 4 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

Issue 4: Environment 

VA requires that PPE be donned prior to entering and worn while in the decontamination

area to protect employees from exposure to contaminates.8 We inspected

123 decontamination areas and observed that employees in 110 (89 percent) areas

appropriately donned PPE prior to entering and wore all required PPE while in the

decontamination areas.

VA requires that ventilation systems be inspected and that filters be changed at least

quarterly in RME reprocessing areas.9 The following table shows RME reprocessing

areas inspected and compliance rates:

Location Ventilation System 

Inspections 

(percent compliance) 

Filter Changes 

(percent compliance) 

SPD 87 (39/45) 87 (39/45) 

OR 88 (30/34) 88 (30/34) 

Bronchoscopy 65 (11/17) 71 (12/17) 

GI/Endoscopy 77 (24/31) 81 (25/31) 

GU/Urology 83 (5/6) 83 (5/6) 

VA requires that sterile items be stored in controlled conditions that protect against

extreme temperatures and humidity. Temperatures must be maintained between 65 and

72 degrees Fahrenheit, and humidity must be 35 to 75 percent.10 Of the 61 sterile storage

areas inspected, 53 (87 percent) were maintained within the acceptable temperature

range, and 41 (67 percent) were within acceptable humidity levels.

We recommended that appropriate PPE be donned before entering and worn in

decontamination areas. We also recommended that ventilation systems be inspected and

filters be changed quarterly in all reprocessing areas and that temperature and humidity

be monitored and maintained within acceptable ranges in sterile storage areas.

Issue 5: Reporting to Executive-Level Committee 

VHA requires that RME activities, such as validation of staff competency, compliance

with established SOPs, results of infection prevention and control monitoring, and risk

management activities, be reported to the Executive Committee of the Medical Staff

(ECMS).11 Senior managers must have oversight of RME practices to address identified

problems expediently. Without appropriate oversight, patients’ safety may be

compromised. Of the 45 facilities inspected, 37 (82 percent) had documented ECMS

discussions of all required elements.

8 VA Handbook 7176.

9 VA Handbook 7176.

10 VA Handbook 7176. 11 VHA Directive 2009-004.

VA Office of Inspector General 5 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

We recommended that processes for consistent internal oversight of RME activities be

established to ensure senior management involvement.

Conclusions 

VHA facilities recognized the importance of safe and consistent RME practices and had

taken steps to improve compliance. Despite VHA’s efforts to fully comply with proper

reprocessing procedures, problems in RME practices continue to occur. It is appropriate

at this time to consider changes to the current management approach to ensure that RME

is properly reprocessed. The identification of technology needs, changes in personnel

policies, and changes in procurement strategies are among the areas that VA should

review. Compliance with applicable RME requirements needs to improve in the

following areas: (1) SOPs, (2) training and competency assessment, (3) flash sterilization,

(4) environment, and (5) reporting to the ECMS.

Recommendations 

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

conjunction with VISN and facility senior managers, ensures that SOPs are current,

consistent with manufacturers’ instructions, and located within the reprocessing areas.

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

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

follow SOPs, that supervisors monitor compliance, and that annual training and

competency assessments are completed and documented.

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

conjunction with VISN and facility senior managers, ensures that flash sterilization is

used only in emergent situations, that supervisors monitor compliance, and that managers

assess and document annual competencies for employees who perform flash sterilization.

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

conjunction with VISN and facility senior managers, ensures that appropriate PPE is

donned before entering and worn in decontamination areas.

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

conjunction with VISN and facility senior managers, ensures that ventilation systems are

inspected and filters are changed quarterly in all reprocessing areas and that temperature

and humidity are monitored and maintained within acceptable ranges in sterile storage

areas.

Recommendation 6. We recommended that the Under Secretary for Health, in

conjunction with VISN and facility senior managers, ensures that processes for consistent

VA Office of Inspector General 6 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

internal oversight of RME activities are established to ensure senior management

involvement.

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 complete.

 (original signed by:) 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 7 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date: Mar 03, 2011

From: Under Secretary for Health (10)

Subject: OIG Healthcare Inspection Draft Report – Evaluation of

Reusable Medical Equipment Practices in Veterans Health

Administration Facilities (VAIQ 7068652)

To: Assistant Inspector General for Healthcare Inspections (54)

1. I have reviewed the draft report and concur with all six 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 (10B5) at (202) 461-7014.

(original signed by:) 

Robert A. Petzel, M.D.

Attachment

VA Office of Inspector General 8 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

VETERANS HEALTH ADMINISTRATION (VHA) 

Action Plan 

OIG Draft Report: Healthcare Inspection, Evaluation of Reusable
 

Medical Equipment Practices in Veterans Health Administration
 

Facilities
 

Date of Draft Report: December 20, 2010

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

SOPs are current, consistent with manufacturers’ instructions, and located

within the reprocessing areas.

VHA Comments

Concur

VHA Directive 2009-031, Improving Safety in the Use of Reusable

Medical Equipment through Standardization of Organizational Structure

and Reprocessing Requirements, dated June 26, 2009, requires that

standard operating procedures (SOP) be current and consistent with

manufacturers’ instructions. To ensure compliance with this directive, as

well as to ensure that these SOPs are located in the reprocessing areas, the

Deputy Under Secretary for Operations and Management (DUSHOM) sent

a memo to all Veterans Health Administration (VHA) facilities in

October 2010 requiring that facilities perform self-inspections of Sterile

Processing Departments (SPD) six times per year and all Veterans

Integrated Service Networks (VISNs) to perform inspections three times

per year. After reviewing initial facility inspections, SPD Operations

identified best practices and compiled these into a standardized data

collection tool. This tool was sent to the field on February 14, 2011, and

will be used from that date forward for all VISN and facility inspections.

This tool requires inspectors to verify that SOPs are in place. The

DUSHOM will monitor compliance by reviewing its SharePoint database

VA Office of Inspector General 9 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

to check both for completion of the inspections, as well as to identify

systemic issues and trends.

Completed February 14, 2011

In addition, although not required by the Office of Inspector General (OIG),

VHA is not only ensuring compliance with existing directives, but is also

moving towards standardization of all SOPs for the reprocessing of

reusable medical equipment (RME). The National Program Office for

Sterile Processing Department (SPD Operations) has contracted with Best

Practice Professionals to provide access to the One Sourcedocs database to

obtain manufacturers’ instructions for use (IFU). This database also

provides Tech Ready documents that can be used as the basis for

developing SOPs based on the IFUs. VHA will implement the use of these

Tech Ready documents as the basis for development of standardized SOPs,

beginning no later than June 1, 2011. The use of standardized SOPs is a

step toward conformance with the International Organization for

Standardization (ISO) 9001-2008 Quality Management Systems (QMS)

requirements related to sterile processing. The availability of current IFUs

to all facilities enhances efforts to attain standardization. Three (3) training

sessions on how to use One Sourcedocs were conducted via webinar with

approximately 300 VHA SPD personnel and Nurse Executives attending.

Additional training sessions will be scheduled as needed.

For targeted groups of instruments without Tech Ready documents, SPD

Operations workgroups have convened to write SOPs. For dental

instruments, for example, these SOPs have been drafted and are pending

manufacturers’ approval prior to deployment to the field.

The Veterans Engineering Resource Centers (VERC) are engaged in many

efforts to promote quality reprocessing through technological innovation

and process improvement. In particular, VERCs are exploring innovative

ways to improve existing SOPs by identifying steps critical to the outcome

that require special quality controls and by simplifying and error-proofing

SOPs to include novel ways to display processes and make explanations

more accessible to the employees who use them.

In process Use of Tech Ready

documents to begin

June 1, 2011

Recommendation 2. We recommended that the Under Secretary for

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

employees consistently follow SOPs, that supervisors monitor compliance,

VA Office of Inspector General 10 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

and that annual training and competency assessments are completed and

documented.

VHA Comments

Concur

The VISN and facility inspection processes described in the response to

Recommendation 1 will be used to ensure that employees consistently

follow SOPs and that annual training and competency assessments are

complete and documented. In addition, staff from SPD Operations within

the DUSHOM will perform site visits to provide additional oversight to

ensure that annual training and competency assessments are complete.

During Fiscal Year (FY) 2010 a total of 22 site visits were performed. To

date in FY 2011, a total of eight site visits have been performed with a total

of 18 pending visits prior to the end of FY 2011.

In addition, although not required by the OIG, staff in SPD Operations have

made numerous improvements to the educational requirements for SPD

staff. SPD Operations has partnered with the VHA Office of Clinical

Consultation and Compliance (OCCC) to conduct a standardized, extensive

educational program and maintain records of attendance through the

International Association of Healthcare Central Services Material

Management (IAHCSMM). During FY 2010, VHA’s own Level 2 training

was revised to include a standardized curriculum and certification

examination. During FY 2010, four Level 2 classes were offered and

attended by more than 200 SPD professionals and managers.

The IAHCSMM recognizes Level 2 certification within VHA as an

alternate means of certification. IAHCSMM is an internationally

recognized professional organization dedicated to the education and

certification of SPD personnel. VA staff are being encouraged to apply for

this alternate IAHCSMM certification. In addition, VHA contracted with

IAHCSMM to train 71 attendees at a course held on September 24, 2010,

and 91 attendees on October 8, 2010.

During FY 2011, VHA has continued to expand its extensive commitment

to professional certification and education of its SPD workforce. SPD

Operations and OCCC offered two Level 2 classes with two additional

classes scheduled for the remainder of FY 2011. One additional

IAHCSMM training is being offered by SPD Operations in collaboration

with OCCC during the first quarter of FY 2011.

Completed January 2011

VA Office of Inspector General 11 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

Recommendation 3. We recommended that the Under Secretary for

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

flash sterilization is used only in emergent situations, that supervisors

monitor compliance, and that managers complete and document annual

competency assessments for employees who perform flash sterilization.

VHA Comments

Concur

The use of flash sterilization and competencies of employees performing

flash sterilization are being monitored during the VISN and facility

inspection processes described in the response to Recommendation 1.

Completed February 14, 2011

Recommendation 4: We recommended that the Under Secretary for

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

appropriate PPE is donned before entering and worn in decontamination

areas.

VHA Comments

Concur

The DUSHOM will clarify the requirements for use of personal protective

equipment (PPE) in decontamination areas to implement Code of Federal

Regulations (CFR) 1910.1030, Blood Borne Pathogens Standard. This will

include initial and annual training about hazards in SPD decontamination

arising from blood and body fluids, guidance on what PPE is required to

address various exposures and activities, information on appropriate care

for injuries from using sharps, and information on the Hepatitis B

vaccination requirements.

During its site inspections, SPD Operations will evaluate and enforce these

requirements through documentation of the appropriate use of PPE. The

VISN and facility inspections, totaling nine per year, will also ensure that

employees wear appropriate PPE. Also, training sessions will reinforce the

need to wear PPE.

Completed September 30, 2011

Recommendation 5: We recommended that the Under Secretary for

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

ventilation systems are inspected and filters are changed quarterly in all

VA Office of Inspector General 12 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

reprocessing areas and that temperature and humidity are monitored and

maintained within acceptable ranges in sterile storage areas.

VHA Comments

Concur

To assess the heating, ventilation, and air conditioning (HVAC) needs at

the facility level, SPD Operations will survey each VISN about what, if

any, HVAC equipment is required to meet the temperature and humidity

requirements in SPDs and other areas in the facilities. The DUSHOM will

develop an action plan to address any deficiencies noted from the surveys.

In process Surveys and action plans

to be completed by

September 30, 2011

Recommendation 6: We recommended that the Under Secretary for

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

processes for consistent internal oversight of RME activities are established

to ensure senior management involvement.

VHA Comments

Concur

As described above, a standardized template has been developed and

deployed to the field requiring facilities to conduct six inspections per year

and VISNs to conduct three unannounced inspections per year (see

Recommendation 1). This template may be revised based upon field input

and utilization. These inspections are being reviewed, with results tracked

and trended at the VA Central Office (VACO) level to refine future

oversight methods. Facility and VISN leadership will remain responsible

for remedying issues identified during these inspections. Results of the

inspections will be reported quarterly, beginning in the third quarter of

FY 2011, to senior managers at the local, VISN, and VACO levels. The

results will be used to target future RME initiatives. SPD Operations will

provide this information to OCCC.

Completed February 14, 2011

Although not required by OIG, OCCC has been charged with ensuring that

SPDs meet the ISO 9001-2008 QMS requirements to reduce variation and

increase standardization of processes to the maximum extent possible

throughout VHA. OCCC will begin consultative visits in FY 2011 to

VA Office of Inspector General 13 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

provide assistance and guidance to facilities in reaching compliance with

the ISO-9001-2008 QMS principles in SPD departments. OCCC will

provide facilities with consultative resources regarding ISO 9001 standards

and follow-up visits to help them achieve these goals.

In process Throughout FY 2011

Veterans Health Administration

March 2011

VA Office of Inspector General 14 
Evaluation of Reusable Medical Equipment Practices in Veterans Health Administration Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact	 Deborah Howard

Director, San Diego Office of Healthcare Inspections

Acknowledgments	 Lisa Barnes

Jennifer Christensen

Donna Giroux

Kathy Gudgell

Douglas Henao

Stephanie Hensel

Tishanna McCutchen

Clarissa Reynolds

Kathleen Shimoda

Carol Torczon

Toni Woodard

VA Office of Inspector General 15 
Evaluation of Reusable Medical Equipment 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 16