Comprehensive Healthcare Inspection of the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Clement J. Zablocki VA Medical Center and multiple outpatient clinics in Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The medical center’s executive leadership team had been working together for over two years. Employee satisfaction survey results revealed opportunities for the Deputy Director and Assistant Director to decrease employee feelings of moral distress at work. Patient experience survey data noted satisfaction with care. Survey results for males and females were generally more favorable than VHA results nationally. The review of accreditation findings did not identify any substantial organizational risk factors. The OIG identified significant concerns with sentinel events identification. Executive leaders were generally able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance, and were knowledgeable within their scopes of responsibilities about Strategic Analytics for Improvement and Learning data. The OIG issued 28 recommendations for improvement in seven areas:(1) Quality, Safety, and Value • Committee processes • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Safety and cleanliness • Information security (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up (6) Women’s Health • Gynecologic care coverage • Committee membership • Quality data • Women veteran program manager position (7) High-Risk Processes • Annual risk analysis • Environmental cleanliness • Equipment storage