Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we also provided fraud and integrity awareness briefings to 56 employees. This review focused on seven operational activities and one follow-up review area from the previous CAP review. The medical center complied with selected standards in the physician credentialing and privileging activity. We identified the BE SAFE Initiative as an organizational strength. We made recommendations for improvements in the following six activities and follow-up review area: QM program, environment of care, magnetic resonance imaging safety, coordination of care, medication management, contracted/agency registered nurses, and follow-up on cardiac catheterization laboratory standards.