Mental Health Inspection of the VA Milwaukee Healthcare System in Wisconsin

The VA Office of Inspector General reviewed acute inpatient mental health care at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Inspectors evaluated care in five areas. The OIG inspection team provided preliminary observations to leaders and later issued seven recommendations. The mental health leadership structure relied on shared responsibilities across multiple managers, which leaders perceived led to improved workload management and coverage. The Mental Health Executive Council did not include required veteran representation, limiting opportunities for veterans to influence the quality of care. The inpatient unit implemented recovery oriented practices. Veterans had daily interdisciplinary programming and access to natural light, a sunroom, and computer kiosks. Staff engaged consistently with veterans, and leaders supported recovery focused approaches. Inspectors identified gaps in clinical care coordination. Staff did not always document veterans’ legal status at admission or discussions about medication risks and benefits. Discharge instructions sometimes used undefined abbreviations or did not explain the purpose of medications, which could hinder veterans’ ability to safely manage their medications.

Staff completed required suicide risk screenings and safety plans before discharge. However, some staff had not completed mandatory suicide prevention training. Required safety inspections on the inpatient unit were completed and a ligature risk was corrected quickly, but a key team member did not attend inspections consistently. Several staff and volunteers also did not complete required training. The recommendations called for veteran participation on the Mental Health Executive Council, improved documentation practices, clearer discharge instructions, completion of required suicide prevention training, and full participation in environmental safety processes. VA leaders concurred with all recommendations and began corrective actions, including strengthening oversight, updating training requirements, improving documentation workflows, adding veteran input to governance, and monitoring compliance through established committees. These efforts are intended to improve the safety, quality, and recovery orientation of inpatient mental health care.