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

Report Information

Issue Date
Report Number
22-04134-63
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
Clinical Care Services Operations
Medical Staff Privileging Credentialing
Mental Health
Major Management Challenges
Healthcare Services
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (focusing on suicide prevention initiatives)

The OIG issued six recommendations for improvement in two areas:
1.    Environment of care
•    Clean and safe patient areas
•    Well-maintained medical center
•    Medication access
•    Temperature- and humidity-controlled storage rooms

2.    Mental health
•    Comprehensive Suicide Risk Evaluations
•    Notification of suicidal behaviors

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff keep all areas clean and safe.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff keep the medical center well maintained.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Pharmacy Services limits medication access to approved staff members.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.