Healthcare Facility Inspection of the William S. Middleton Memorial Veterans Hospital and Clinics in Madison, Wisconsin

Report Information

Issue Date
Report Number
25-00254-277
VISN
3
State
Wisconsin
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Appointment Scheduling and Wait Times
Care Coordination
Community Care
Healthcare Infrastructure
Patient Care Services Operations
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the William S. Middleton Memorial Veterans Hospital and Clinics in Madison, Wisconsin.

This evaluation focused on five key domains: 
     •    Culture 
     •    Environment of care 
     •    Patient safety 
     •    Integrated veteran care 
     •    Veteran-centered safety net

The OIG made two recommendations for VA to correct identified issues in one domain: 
     •    Patient safety 
       o    Facility’s policy and service-level workflows for the communication of test results
 

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 takes appropriate action so staff update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe staff members’ roles in the process of communicating test results to providers and patients, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.