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

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Clement J. Zablocki VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. The OIG provided crime awareness briefings to 93 employees. The facility has generally stable executive leadership and active engagement with employees and patients; however, the senior leadership team has opportunities to improve patient safety, quality care, and perceptions about facility leadership. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified multiple organizational risk factors that may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented. The senior leadership team should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 3-star SAIL rating. The OIG noted findings in five of the six areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Deputy Director. The identified areas with deficiencies are: (1) QSV • Review of credentialing and privileging data (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and reporting • Transfer documentation • Resident supervision • Communication with the accepting facility (3) EOC • EOC rounds frequency and attendance • Training for locked mental health unit employees (4) High-Risk Processes: Moderate Sedation • Training for staff who perform moderate sedation (5) Long-Term Care: CNH Oversight • Clinical visits for patients residing in CNHs