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

Report Information

Issue Date
Closure Date
Report Number
20-00075-225
VISN
12
State
Wisconsin
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Recommendations
28
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are documented in Quality Management Oversight Committee minutes when problems or opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria in practitioner profiles for focused professional practice evaluations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate, complete, and document the results of focused professional practice evaluations in practitioner profiles.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs consistently collect and review ongoing professional practice evaluation data for the determination to recommend continuation of privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that licensed independent practitioners’ ongoing professional practice evaluations are completed by providers with similar training and privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Medical Executive Committee meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and makes sure that biohazardous rooms are not used to store clean items.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Assistant Director determines the reasons for noncompliance and ensures that clean/sterile storeroom solid-bottom shelves are clean.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center and outpatient clinic buildings.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures that patient care equipment is clean and ready for use.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020

The Medical Center Director ensures that Office of Information Technology leaders determine the reasons for noncompliance and ensures that access is controlled to information technology rooms.

No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment to include a history of substance abuse and psychological disease on all patients prior to initiating long-term opioid therapy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent consistently for patients who are initiating long-term opioid therapy.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within three months and assess adherence to the pain management plan of care and effectiveness of interventions.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the prescribed time frame and include documentation of the patient’s preference for a telephone call, if applicable.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff determines the reasons for noncompliance and ensures that processes and procedures are in place to ensure gynecological care is available 24 hours a day, 7 days per week.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings and report to executive leaders.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that required quality assurance data related to women veterans’ health care services are collected and tracked for improvement opportunities.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020

The Chief of Staff determines the reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.

No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs and documents an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.

No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that the written cleaning schedule for Sterile Processing Services is enforced.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected scopes are stored properly.