VA Health Care
Preliminary Observations on the Purchasing and Tracking of Supplies and Medical Equipment and the Potential Impact on Veterans' Safety Gao ID: GAO-10-1038T September 23, 2010VA clinicians use expendable medical supplies--disposable items that are generally used one time--and reusable medical equipment (RME), which is designed to be reused for multiple patients. VA has policies that VA medical centers (VAMC) must follow when purchasing such supplies and equipment and tracking--that is, accounting for--these items at VAMCs. GAO was asked to evaluate VA's purchasing and tracking of expendable medical supplies and RME and their potential impact on veterans' safety. This testimony is based on GAO's ongoing work and provides preliminary observations on (1) the extent of compliance with VA's requirements for purchasing and tracking of expendable medical supplies and RME and (2) steps VA plans to take to improve its oversight of VAMCs' purchasing and tracking of expendable medical supplies and RME. GAO reviewed VA policies and selected three requirements that GAO determined to be relevant to patient safety. At each of the five VAMCs GAO visited, GAO reviewed documents used to identify issues related to the three requirements and interviewed officials to gather further information on these issues. The VAMCs GAO visited represent different surgical complexity groups, sizes of veteran populations served, and geographic regions. GAO also interviewed VA headquarters officials and obtained and reviewed documents regarding VA headquarters' oversight. GAO shared the information in this statement with VA officials.
During its preliminary work at the five selected VAMCs, GAO found inconsistent compliance with the three VA purchasing and tracking requirements selected for review. Noncompliance with these requirements created potential risks to veterans' safety. (1) Requirement for VAMC committee review and approval. At two of the VAMCs, officials stated that the required designated committee review and approval occurred for all of the expendable medical supplies and RME that the VAMCs had not previously purchased. These reviews are designed to evaluate the cost of the purchase as well as its likely impact on veterans' care. However, at the remaining three VAMCs, officials stated that the required committee review and approval of the expendable medical supplies, such as those used in conjunction with dialysis machines, did not always occur. As a result, these purchases were made without evaluating the likely impact on veterans' care. (2) Requirement for signatures of purchasing and approving officials. At one of the VAMCs, VAMC officials discovered that a staff member in a dialysis department ordered an expendable medical supply item for use in dialysis machines, without obtaining the required signature of an approving official. That staff member ordered an incorrect item, the use of which presented a risk of exposing veterans to infectious diseases, such as Human Immunodeficiency Virus. (3) Requirement for entering information in VA's inventory management systems. Officials from one of the five VAMCs told GAO that information about expendable medical supplies that were ordered on a recurring basis was entered into the appropriate inventory management system, as required. At the remaining four VAMCs, officials told GAO that information about certain expendable medical supplies--those used in a limited number of clinical departments such as dialysis departments--was not always entered into the system. This lack of information can pose a potential risk to veterans' safety; in the event of a recall of these items, these VAMCs may have difficulty determining whether they possess the targeted item. VA reports that it plans to improve its oversight of VAMCs' purchasing and tracking of expendable medical supplies and RME. For example, VA headquarters officials stated that, effective October 1, 2010, VA plans to shift greater responsibility for reviews of purchase card transactions from the VAMCs to the Veterans Integrated Service Networks, which are responsible for overseeing VAMCs. VA headquarters officials also told GAO that VA is developing a new inventory management system, which it expects will help improve VA's ability to track information about expendable medical supplies and RME across VAMCs. VA expects this new system to be operational in March 2011.
GAO-10-1038T, VA Health Care: Preliminary Observations on the Purchasing and Tracking of Supplies and Medical Equipment and the Potential Impact on Veterans' Safety
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Testimony:
Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, September 23, 2010:
VA Health Care:
Preliminary Observations on the Purchasing and Tracking of Supplies
and Medical Equipment and the Potential Impact on Veterans' Safety:
Statement of Debra A. Draper:
Director, Health Care:
GAO-10-1038T:
GAO Highlights:
Highlights of GAO-10-1038T, a testimony before the Subcommittee on
Health, Committee on Veterans‘ Affairs, House of Representatives.
Why GAO Did This Study:
VA clinicians use expendable medical supplies”disposable items that
are generally used one time”and reusable medical equipment (RME),
which is designed to be reused for multiple patients. VA has policies
that VA medical centers (VAMC) must follow when purchasing such
supplies and equipment and tracking”that is, accounting for”these
items at VAMCs.
GAO was asked to evaluate VA‘s purchasing and tracking of expendable
medical supplies and RME and their potential impact on veterans‘
safety. This testimony is based on GAO‘s ongoing work and provides
preliminary observations on (1) the extent of compliance with VA‘s
requirements for purchasing and tracking of expendable medical
supplies and RME and (2) steps VA plans to take to improve its
oversight of VAMCs‘ purchasing and tracking of expendable medical
supplies and RME. GAO reviewed VA policies and selected three
requirements that GAO determined to be relevant to patient safety. At
each of the five VAMCs GAO visited, GAO reviewed documents used to
identify issues related to the three requirements and interviewed
officials to gather further information on these issues. The VAMCs GAO
visited represent different surgical complexity groups, sizes of
veteran populations served, and geographic regions. GAO also
interviewed VA headquarters officials and obtained and reviewed
documents regarding VA headquarters‘ oversight. GAO shared the
information in this statement with VA officials.
What GAO Found:
During its preliminary work at the five selected VAMCs, GAO found
inconsistent compliance with the three VA purchasing and tracking
requirements selected for review. Noncompliance with these
requirements created potential risks to veterans‘ safety.
* Requirement for VAMC committee review and approval. At two of the
VAMCs, officials stated that the required designated committee review
and approval occurred for all of the expendable medical supplies and
RME that the VAMCs had not previously purchased. These reviews are
designed to evaluate the cost of the purchase as well as its likely
impact on veterans‘ care. However, at the remaining three VAMCs,
officials stated that the required committee review and approval of
the expendable medical supplies, such as those used in conjunction
with dialysis machines, did not always occur. As a result, these
purchases were made without evaluating the likely impact on veterans‘
care.
* Requirement for signatures of purchasing and approving officials. At
one of the VAMCs, VAMC officials discovered that a staff member in a
dialysis department ordered an expendable medical supply item for use
in dialysis machines, without obtaining the required signature of an
approving official. That staff member ordered an incorrect item, the
use of which presented a risk of exposing veterans to infectious
diseases, such as Human Immunodeficiency Virus.
* Requirement for entering information in VA‘s inventory management
systems. Officials from one of the five VAMCs told GAO that
information about expendable medical supplies that were ordered on a
recurring basis was entered into the appropriate inventory management
system, as required. At the remaining four VAMCs, officials told GAO
that information about certain expendable medical supplies”those used
in a limited number of clinical departments such as dialysis
departments”was not always entered into the system. This lack of
information can pose a potential risk to veterans‘ safety; in the
event of a recall of these items, these VAMCs may have difficulty
determining whether they possess the targeted item.
VA reports that it plans to improve its oversight of VAMCs‘ purchasing
and tracking of expendable medical supplies and RME. For example, VA
headquarters officials stated that, effective October 1, 2010, VA
plans to shift greater responsibility for reviews of purchase card
transactions from the VAMCs to the Veterans Integrated Service
Networks, which are responsible for overseeing VAMCs. VA headquarters
officials also told GAO that VA is developing a new inventory
management system, which it expects will help improve VA‘s ability to
track information about expendable medical supplies and RME across
VAMCs. VA expects this new system to be operational in March 2011.
View [hyperlink, http://www.gao.gov/products/GAO-10-1038T] or key
components. For more information, contact Debra A. Draper at (202) 512-
7114 or draperd@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today as you discuss the Department of
Veterans Affairs' (VA) contracting and procurement practices. VA
operates one of the largest integrated health care delivery systems in
the United States, providing care to over 5.5 million veterans
annually. Organized into 21 Veterans Integrated Service Networks
(VISN), VA's health care system includes 153 VA medical centers (VAMC)
nationwide that offer a variety of outpatient, residential, and
inpatient services.[Footnote 1] These services range from primary care
to complex specialty care, such as cardiac and spinal cord injury
care. In providing these health care services to veterans, VA
clinicians at VAMCs use supplies and equipment that must be purchased
by VA. These include expendable medical supplies, such as needles and
scalpel blades, which are generally used once, and reusable medical
equipment (RME), which is designed to be reused for multiple patients
and includes such equipment as endoscopes and some surgical
instruments.
VA has established policies that VAMCs are required to follow when
purchasing items such as expendable medical supplies or RME and
tracking--that is, accounting for--these items at their facilities.
[Footnote 2] For example, VA requires that a designated VAMC committee
review and approve purchases of any expendable medical supplies or RME
that the VAMC has not previously purchased. VA also requires that
VAMCs enter information about certain expendable medical supplies and
certain RME at their facilities into the appropriate inventory
management system. VA's purchasing and tracking policies help ensure
that VAMCs make effective use of available resources and that they
know which supplies and equipment are being used at their facilities.
VA's purchasing and tracking policies are also designed, in part, to
help ensure the safety of veterans who receive care at VAMCs. For
example, VAMCs need information on the RME in use at their facilities
in order to ensure that they have procedures for properly reprocessing
[Footnote 3] these items. VAMCs also need information on the supplies
and equipment in use in their facilities in order to determine when
they have expendable medical supplies or RME that are the subject of a
manufacturer or U.S. Food and Drug Administration (FDA) recall or a
patient safety alert.[Footnote 4]
Congressional committees and certain members of Congress have raised
questions about VAMCs' purchasing and tracking of expendable medical
supplies and RME and their potential impact on veterans' safety. My
testimony today consists of preliminary observations as part of our
ongoing work on VA's oversight of compliance with its policies for
purchasing and tracking expendable medical supplies and RME. These
observations, based on site visits to five selected VAMCs, raise
concerns about the safety of veterans receiving care at these
facilities. We cannot determine the extent to which the purchasing and
tracking problems in the five selected VAMCs reflect the broader VA
health care system.
In my remarks today I will provide preliminary observations on (1) the
extent of compliance with VA's requirements for purchasing and
tracking of expendable medical supplies and RME and (2) steps VA
headquarters plans to take to improve its oversight of VAMCs'
purchasing and tracking of expendable medical supplies and RME.
To identify the extent of VAMCs' compliance with VA's requirements for
purchasing and tracking of expendable medical supplies and RME, we
reviewed VA policies[Footnote 5] and selected three purchasing and
tracking requirements that we determined were relevant to veterans'
safety issues. The requirements we selected are (1) having a
designated VAMC committee review and approve purchases of any
expendable medical supplies and RME that the VAMC has not previously
purchased, (2) obtaining signatures of purchasing and approving
officials, and (3) entering information about expendable medical
supplies and RME at VAMCs into VA's inventory management systems. We
selected these requirements to inform our discussions with VAMC
officials about patient safety incidents related to the purchase and
tracking of expendable medical supplies and RME that were identified
at certain VAMCs in 2009.[Footnote 6] We judgmentally selected five
VAMCs to visit: the VAMCs in Albany, New York; Cheyenne, Wyoming;
Detroit, Michigan; Miami, Florida; and Palo Alto, California. These
VAMCs represent different surgical complexity groups,[Footnote 7]
sizes of veteran populations served, and geographic regions. At the
five VAMCs, we reviewed applicable VAMC committee meeting
minutes[Footnote 8] and other documentation used to identify problems
related to the three purchasing and tracking requirements we selected
for our review. We also interviewed VAMC officials to gather
additional information on these problems. To obtain information on
steps VA headquarters plans to take to improve its oversight of VAMCs'
purchasing and tracking of expendable medical supplies and RME, we
interviewed VA headquarters officials responsible for overseeing
VAMCs' purchasing of expendable medical supplies and RME. In addition,
we obtained and reviewed relevant documents regarding VA headquarters'
oversight, including internal reports and policy memorandums. We
shared the information provided in this statement with VA headquarters
officials.
We are conducting this performance audit in accordance with generally
accepted government auditing standards. We conducted the work for this
statement from March 2010 to September 2010. The audit standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings
and conclusions based on our audit objectives. We believe that the
evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background:
VA policy specifies how VAMCs can purchase expendable medical supplies
and RME. VAMCs can purchase expendable medical supplies and RME
through their acquisition departments or through purchase card
holders, who have been granted the authority to make such purchases.
Purchase cards are issued to certain VAMC staff, including staff from
clinical departments, to acquire a range of goods and services,
including those used to provide care to veterans. According to VA, as
of the third quarter of 2010, there were about 27,000 purchase cards
in use across VA's health care system.
VA has two inventory management systems, which VAMCs use to track the
type and quantity of supplies and equipment in the facilities. Each
VAMC is responsible for maintaining its own systems and for entering
information about certain expendable medical supplies and certain RME
in the facilities into the appropriate system. Specifically, the
Generic Inventory Package (GIP) is used to track information about
expendable medical supplies that are ordered on a recurring basis.
[Footnote 9] The Automated Engineering Management System/Medical
Equipment Reporting System (AEMS/MERS) is used to track information
about RME that is valued at $5,000 or more and has a useful life of 2
years or more.[Footnote 10] VAMC officials told us they use
information about the items in their facilities for a variety of
purposes, for example, to readily determine whether they have
expendable medical supplies or RME that are the subject of a
manufacturer or FDA recall or a patient safety alert.
VA's purchasing and tracking policies include the following three
requirements for VAMCs:
1. A designated VAMC committee must review and approve proposed
purchases of any expendable medical supplies or RME that have not been
previously purchased by the VAMC.[Footnote 11] The committee, which
typically includes administrative staff and clinicians from various
departments, reviews the proposed purchases to evaluate the cost of
the purchase as well as its likely impact on veterans' care.[Footnote
12] For example, the committee that reviews and approves proposed RME
purchases often includes a representative from the department
responsible for reprocessing RME, in order to determine whether the
VAMC has the capability to reprocess--clean and disinfect or
sterilize--the item correctly and that staff are appropriately trained
to do so. Proper reprocessing of RME is important to ensure that RME
is safe to use and that veterans are not exposed to infectious
diseases, such as Human Immunodeficiency Virus (HIV), during treatment.
2. All approvals for purchases of expendable medical supplies or RME
must be signed by two officials, the official placing the order and
the official responsible for approving the purchase.[Footnote 13]
3. VAMCs must enter information on all expendable medical supplies
that are ordered on a recurring basis and all RME that is valued at
$5,000 or more and has a useful life of 2 years or more into the
appropriate inventory management system, either GIP or AEMS/MERS.
[Footnote 14] VA does not require information about RME that is valued
at less than $5,000 to be entered into AEMS/MERS.
GAO's Preliminary Work Identified Examples of Inconsistent Compliance
with VA's Purchasing and Tracking Requirements at Five Selected VAMCs:
At the five VAMCs we visited, our preliminary work identified examples
of inconsistent compliance with the three purchasing and tracking
requirements we selected for our review. In some cases, noncompliance
with these requirements created potential risks to veterans' safety.
We are continuing to conduct this work.
VAMC committee review and approval.
* Officials at two of the five VAMCs we visited stated that VAMC
committees reviewed and approved all of the expendable medical
supplies the VAMCs purchased for the first time. However, at the
remaining three VAMCs, officials told us that VAMC committees did not
conduct these reviews in all cases. Officials from these three VAMCs
told us that certain expendable medical supplies--for example, new
specialty supplies--were purchased without VAMC committee review and
approval. Specialty supplies, such as those used in conjunction with
dialysis machines, are expendable medical supplies that are only used
in a limited number of clinical departments. Without obtaining that
review and approval, however, the VAMCs purchased these supplies
without evaluating their cost effectiveness or likely impact on
veterans' care.
* At one VAMC we visited, officials told us that clinical department
staff were permitted to purchase certain RME--surgical and dental
instruments--using purchase cards and that these purchases were not
reviewed and approved by a committee. Therefore, the VAMC had no
assurance that RME purchased by clinical department staff using
purchase cards had been reviewed and approved by a committee before it
was purchased for the first time. As a result, these purchases may
have been made without assurance that they were cost effective and
safe for use on veterans and that the VAMC had the capability and
trained staff to reprocess these items correctly.
Signatures of purchasing and approving officials.
* At one of the five VAMCs we visited, VAMC officials discovered that
one staff member working in a dialysis department purchased specialty
supplies without obtaining the required signature of an appropriate
approving official. That staff member was responsible for ordering an
item for use in 17 dialysis machines that was impermeable to blood and
would thus prevent blood from entering the dialysis machine. However,
the staff member ordered an incorrect item, which was permeable to
blood, allowing blood to pass into the machine. After the item was
purchased, the incorrect item was used for 83 veterans, resulting in
potential cross-contamination of these veterans' blood, which may have
exposed them to infectious diseases, such as HIV, Hepatitis B, and
Hepatitis C.[Footnote 15]
Entry of information about items into VA's inventory management
systems.
* At the time of our site visits, officials from one of the five VAMCs
we visited told us that information about expendable medical supplies
that were ordered on a recurring basis was entered into GIP, as
required. In contrast, officials at the remaining four VAMCs told us
that information about certain expendable supplies that were ordered
on a recurring basis, such as specialty supplies, was not always
entered into GIP. Since our visit, one of the four VAMCs has reported
that it has begun to enter all expendable medical supplies that are
ordered on a recurring basis, including specialty supplies, into GIP.
By not following VA's policy governing GIP, VAMCs have an incomplete
record of the expendable medical supplies in use at their facilities.
This lack of information can pose a potential risk to veterans'
safety. For example, VAMCs may have difficulty ensuring that expired
supplies are removed from patient care areas. In addition, in the
event of a manufacturer or FDA recall or patient safety alert related
to a specialty supply, VAMCs may have difficulty determining whether
they possess the targeted expendable medical supply.
* Officials at one VAMC we visited told us about an issue related to
tracking RME in AEMS/MERS that contributed to a patient safety
incident, even though the VAMC was not out of compliance with VA's
requirement for entering information on RME into AEMS/MERS.
Specifically, because VA policy does not require RME valued under
$5,000 to be entered into AEMS/MERS, an auxiliary water tube, a type
of RME valued under $5,000 that is used with a colonoscope, was not
listed in AEMS/MERS.[Footnote 16] According to VAMC officials and the
VA Office of the Inspector General, in response to a patient safety
alert that was issued on the auxiliary water tube in December 2008,
officials from the VAMC checked their inventory management systems and
concluded--incorrectly--that the tube was not used at the facility.
[Footnote 17] However, in March 2009, the VAMC discovered that the
tube was in use and was not being reprocessed correctly, potentially
exposing 2,526 veterans to infectious diseases, such as HIV, Hepatitis
B, and Hepatitis C.[Footnote 18]
In addition, officials from VA headquarters told us that when
information about certain RME is entered into AEMS/MERS, it is
sometimes done inconsistently. The officials explained that this is
because AEMS/MERS allows users to enter different names for the same
type of RME. As a result, in the case of a manufacturer or FDA recall
or patient safety alert related to a specific type of RME, VAMCs may
have difficulty determining whether they have that specific type of
RME.
VA Reports It Plans to Change Its Oversight of Purchasing and Tracking:
During our preliminary work, we discussed with VA headquarters
officials examples of steps VA plans to take to improve its oversight
of VAMCs' purchasing and tracking of expendable medical supplies and
RME. For example, VA plans to change its oversight of the use of
purchase cards. Specifically, VA headquarters officials told us that
designated VAMC staff are currently responsible for reviewing purchase
card transactions to ensure that purchases are appropriate. However,
one VA headquarters official stated that these reviews are currently
conducted inconsistently, with some being more rigorous than others.
VA headquarters officials stated that VA plans to shift greater
responsibility for these reviews from the VAMCs to the VISNs,
effective October 1, 2010. In addition, VA plans to standardize the
reviews by, for example, adding a checklist for reviewers. Because
this change has not yet been implemented across VA, we can not
evaluate the extent to which it will address the appropriateness of
purchases using purchase cards.
Our preliminary work also shows that VA plans to create a new
inventory management system. VA headquarters officials told us that
they are developing a new inventory management system--Strategic Asset
Management (SAM)--which will replace GIP and AEMS/MERS and will
include standardized names for expendable medical supplies and
RME.[Footnote 19] According to these officials, SAM will help address
inconsistencies in how information about these items is entered into
the inventory management systems. VA headquarters officials stated
that SAM will help improve VA's ability to monitor information about
expendable medical supplies and RME across VAMCs. VA provided us with
an implementation plan for SAM, which stated that this new system
would be operational in March 2011. At this time, we have not done
work to determine whether this date is realistic or what challenges VA
will face in implementing it.
Mr. Chairman, this concludes my statement. I would be pleased to
respond to any questions you or other members of the committee may
have.
GAO Contacts and Staff Acknowledgments:
For further information about this statement, please contact Debra A.
Draper at (202) 512-7114 or draperd@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this testimony. Key contributors to this statement
were Randall B. Williamson, Director; Mary Ann Curran, Assistant
Director; David Barish; Alana Burke; Krister Friday; Melanie Krause;
Lisa Motley; and Michael Zose.
[End of section]
Footnotes:
[1] The management of VAMCs is decentralized to the 21 VISNs.
[2] See, for example, VA Handbook 7176, Supply, Processing and
Distribution (SPD) Operational Requirements (Aug. 16, 2002) and
Veterans Health Administration (VHA) Handbook 1761.02, VHA Inventory
Management (Oct. 20, 2009).
[3] Reprocessing refers to the steps by which RME is prepared for
reuse, and includes cleaning and disinfecting or sterilizing the
medical equipment.
[4] A patient safety alert is a notification sent to VAMCs from VA's
National Center for Patient Safety regarding veterans' safety.
[5] We reviewed applicable VA policies, including VA Handbook 7176,
Supply, Processing and Distribution (SPD) Operational Requirements
(Aug. 16, 2002); Department of Veterans Affairs, VA Financial Policies
and Procedures, Volume II, Chapter 6, Miscellaneous Obligations (Jan.
2009); VHA Handbook 1761.02, VHA Inventory Management (Oct. 20, 2009);
and VA Directive 1725.1, Accountability (Apr. 5, 1996).
[6] We are continuing to review VA's policies to determine whether
additional requirements relate to these patient safety incidents and
should be included in our ongoing work.
[7] VA assigns each VAMC a complexity score between 1 and 3 (level 1
is broken down further into 1a, 1b, and 1c), with level 1 being the
most complex, using a facility complexity model. That model uses
multiple variables to measure facility complexity arrayed along 4
categories, namely patient population served, clinical services
offered, education and research complexity, and administrative
complexity.
[8] We reviewed minutes from the following committees: commodity
standards, equipment, infection control, medical executive, and
reusable medical equipment.
[9] GIP is used to track additional items besides expendable medical
supplies, including non-medical supplies.
[10] AEMS/MERS is used to track additional equipment besides RME,
including information technology equipment.
[11] Generally, a VAMC's commodity standards committee reviews and
approves purchases of expendable medical supplies and a VAMC's
equipment committee reviews and approves purchases of RME.
[12] See VA Handbook 7176, Supply, Processing and Distribution (SPD)
Operational Requirements (Aug. 16, 2002).
[13] Department of Veterans Affairs, VA Financial Policies and
Procedures, Volume II, Chapter 6, Miscellaneous Obligations (Jan.
2009).
[14] See VHA Handbook 1761.02, VHA Inventory Management (Oct. 20,
2009) and VA Directive 1725.1, Accountability (Apr. 5, 1996).
[15] As of June 2, 2010, the VAMC reported that all testing has been
completed and that no veterans have acquired infectious diseases as a
result of this incident. The VAMC found that one of the 83 veterans
identified was dialyzed on an uncontaminated machine and therefore
this veteran was not notified or tested for these infectious diseases.
[16] VAMC officials stated that they also checked GIP to determine
whether the auxiliary water tube was listed and determined that it was
not listed in that inventory management system. According to a VA
headquarters official, the auxiliary water tube is not required to be
entered in GIP because it is not ordered on a recurring basis.
[17] See VA Office of the Inspector General, Use and Reprocessing of
Flexible Fiberoptic Endoscopes at VA Medical Facilities, 09-01784-146
(Washington, DC: June 2009).
[18] As of August 17, 2010, the VAMC reported that it has successfully
notified 2,523 of the 2,526 veterans of possible exposure to
infectious diseases and that there were 17 new positive test results.
VA reports that these results are not necessarily linked to RME issues
and it is continuing its evaluation.
[19] SAM will be used to track additional items besides expendable
medical supplies and RME.
[End of section]
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