4.29.2009

Veterans Put at Risk Due to Poor Cleaning Procedures at VA Hospitals

Sometimes the causes and solutions of a problem are not obvious and require careful analysis. For example, I recently wrote about hospital readmissions, a problem identified by a study of Medicare data.

But at other times, something seems so obvious that you can only shake your head in sad wonder.

Case in point: Nearly 11,000 former members of the armed forces may have been exposed to HIV and/or hepatitis because they received endoscopies at three Veterans’ Administration hospitals in the southeast with equipment that hadn’t been cleaned properly.

The problem was first reported early this year. More recently, as reported by The Washington Post in a story by the Associated Press, the number of confirmed cases of hepatitis and HIV is growing, and veterans are frustrated that the VA is not providing much information about the situation.

From a public relations standpoint, it sounds as if the VA is handling the situation badly. However, I would like to focus on what in the VA’s processes led to the problem.

An endoscope is a narrow, flexible tube with a fiber-optic device at the end. It is inserted into the body during colonoscopies and certain ear, nose and throat treatments.


The VA said the problems with the endoscopic equipment had gone on for years, but were discovered in December when it learned the Murfreesboro facility wasn't following cleaning procedures the manufacturer recommended. It issued an internal alert for hospitals to check their procedures, and the problem at Augusta was discovered in January…

The endoscopic equipment is made by Center Valley, Pa.-based Olympus American Inc., and the company has said its recommended cleaning procedures are clear.


Without more information, it is difficult to determine why the manufacturer’s recommendations weren’t being followed. Possible causes include that the manufacturer’s recommendations actually weren’t clear, or that, clear or not, the cleaning procedures weren’t communicated properly, or that the responsible staffers were not properly trained in cleaning procedures.

Whatever the cause, the solution almost certainly involves applying several lean principles: clear communication, creation of standard work, proper training of staff, and regular reviews or audits to ensure that proper practices are being followed.

It is a shame the VA doesn’t seem to understand lean. Our veterans deserve better.

1 comments:

Mark Graban said...

I was going to blog about this... it's not just "put at risk".

3 vets have tested positive for HIV from 3 different sites. It's absolutely shameful that the VA didn't follow the right processes.