Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

Clement J. Zablocki VA Medical Center 

Milwaukee, Wisconsin 

Report No. 07-00060-121 April 27, 2007

VA Office of Inspector General 

Washington, DC 20420 
Office of Inspector General 

Combined Assessment Program Reviews 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care services are 

provided to our Nation's veterans. CAP reviews combine the knowledge and skills 

of the OIG's Offices of Healthcare Inspections and Investigations to provide 

collaborative assessments of VA medical facilities on a cyclical basis. The 

purposes of CAP reviews are to: 

• Evaluate how well VA facilities are accomplishing their missions of providing 

veterans convenient access to high quality medical services. 

• Provide fraud and integrity awareness training to increase employee 

understanding of the potential for program fraud and the requirement to refer 

suspected criminal activity to the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or 

allegations referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Contents 

Page 

Executive Summary ..............................................................................................i

Introduction ..........................................................................................................1

Medical Center Profile..................................................................................................... 1

Objectives and Scope of the Combined Assessment Program Review........................... 2

Results of Review.................................................................................................3

Organizational Strengths ................................................................................................. 3

Seamless Transition Program....................................................................................... 3

Communication Strategies ........................................................................................... 3

Opportunities for Improvement ....................................................................................... 5

Environment of Care .................................................................................................... 5

Contract Community Nursing Home Program ............................................................ 6

Cardiac Catheterization Laboratory Standards ............................................................ 7

Other Areas Reviewed..................................................................................................... 8

Survey of Healthcare Experiences of Patients ............................................................. 8

Diabetes and Atypical Antipsychotic Medications.................................................... 10

Quality Management Program ................................................................................... 12

VA Community Based Outpatient Clinics................................................................. 14

Appendixes 

A. VISN Director’s Comments..................................................................................... 15

B. Medical Center Director’s Comments ..................................................................... 16

C. OIG Contact and Staff Acknowledgments............................................................... 22

D. Report Distribution .................................................................................................. 23

VA Office of Inspector General 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Executive Summary 

Introduction 

During the week of December 4–8, 2006, the Office of Inspector General (OIG) 

conducted a Combined Assessment Program (CAP) review of the Clement J. Zablocki 

VA Medical Center (the 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 training to 200 medical center employees. The medical center is part of 

Veterans Integrated Service Network (VISN) 12. 

Results of Review 

The CAP review covered nine areas. The medical center complied with selected 

standards in the following six areas: 

• Survey of Healthcare Experiences of Patients (SHEP). 

• Diabetes and Atypical Antipsychotic Medications. 

• Laboratory Security. 

• Management of Violent Patients. 

• QM Program. 

• VA Community Based Outpatient Clinics (CBOCs). 

We identified the following organizational strengths: 

• Seamless Transition Program. 

• Communication Strategies. 

We made recommendations in three of the nine areas reviewed. For these areas, the 

medical center needed to: 

• Correct environmental deficiencies. 

• Improve selected aspects of the Contract Community Nursing Home (CNH) Program. 

• Improve the informed consent process and ensure all clinical providers receive 

cardiopulmonary resuscitation (CPR) education. 

This report was prepared under the direction of Ms. Verena Briley-Hudson, Director, and 

Ms. Wachita Haywood, Associate Director, Chicago Office of Healthcare Inspections. 

VA Office of Inspector General i 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Comments 

The VISN and Medical Center Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes A and 

B, pages 15–21, for the full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

 (original signed by:) 

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Introduction 

Medical Center Profile 

Organization. The Clement J. Zablocki VA Medical Center is a tertiary care medical 

center that provides a broad range of inpatient and outpatient health care services. 

Outpatient care is also provided at four 

CBOCs located in Cleveland, Union Grove, 

Appleton, and Green Bay, Wisconsin. The 

medical center is part of VISN 12 and serves a 

veteran population of about 234,953 in a 

primary service area that includes 15 counties 

in the eastern part of Wisconsin. 

Programs. The medical center provides 

spinal cord injury care and medical, surgical, 

mental health, geriatric, and rehabilitation 

services. There are 170 hospital beds and 113 nursing home beds. The medical center 

operates several regional referral and treatment programs, including open heart surgery, 

and a wide array of mental health programs, including programs at the domiciliary level 

of care. The medical center also has sharing agreements that are contracted through the 

VISN’s VA Great Lakes Acquisition Center. 

Affiliations and Research. The medical center is affiliated with the Medical College of 

Wisconsin and supports 142 medical resident positions in 31 training programs. Other 

affiliations provide for training in many health care fields. In fiscal year (FY) 2006, the 

medical center research program had 365 projects and a VA budget of $3.3 million. 

Important areas of research include kidney and gall bladder diseases and oncology. 

Resources. The FY 2006 medical care general purpose budget was $256.9 million. 

FY 2006 staffing totaled 1,931 full-time employee equivalents (FTE), including 135 

physician and 668 nurse FTE. 

Workload. In FY 2006, the medical center treated 53,284 unique patients. The medical 

center provided 50,359 inpatient days of care in the hospital and 29,638 inpatient days of 

care in the Nursing Home Care Unit. The domiciliary provided 93,406 bed days of care. 

The hospital inpatient care workload totaled 6,583 discharges, and the average daily 

census, including nursing home patients, was 475. The outpatient workload was 545,005 

visits. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Objectives and Scope of the Combined Assessment Program Review 

Objectives. CAP reviews are one element of the OIG’s efforts to ensure that our 

Nation’s veterans receive high quality VA health care services. The objectives of the 

CAP review are to: 

• Conduct recurring evaluations of selected health care facility operations focusing on 

patient care administration and QM. 

• Provide fraud and integrity awareness training to increase employee understanding of 

the potential for program fraud and the requirement to refer suspected criminal 

activity to the OIG. 

Scope. We reviewed selected clinical and administrative activities to evaluate the 

effectiveness of patient care administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the process of monitoring the 

quality of care to identify and correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; interviewed managers, employees, 

and patients; and reviewed clinical and administrative records. The review covered the 

following nine activities: 

Cardiac Catheterization Laboratory 

Standards 

Diabetes and Atypical Antipsychotic 

Medications 

Environment of Care 

Laboratory Security 

Management of Violent Patients 

QM Program 

SHEP 

CBOCs 

CNH Program 

The review covered medical center operations for FY 2006 and FY 2007 through 

November 30, 2006, and was done in accordance with OIG standard operating 

procedures for CAP reviews. 

We followed up on one recommendation (Laboratory Security) and two suggestions 

(Environment of Care and Management of Violent Patients) from the previous CAP 

review (Combined Assessment Program Review of the Clement J. Zablocki VA Medical 

Center, Milwaukee, Wisconsin, Report No. 03-00445-173, August 29, 2003). Medical 

center managers were in compliance with the previous recommendation for Laboratory 

Security and our suggestion for Management of Violent Patients, but they needed to 

improve in the Environment of Care. 

In this report we make recommendations for improvement that pertain to issues that are 

significant enough to be monitored by the OIG until corrective actions are implemented. 

Activities in the section entitled “Other Review Topics” have no reportable conditions.

VA Office of Inspector General 2 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Results of Review 

Organizational Strengths 

Seamless Transition Program – Ensures Access to Care for Operation 

Enduring Freedom/Operation Iraqi Freedom Veterans 

The medical center reaches out to returning combat veterans and their families by 

facilitating a smooth transition from the unique demands of serving on active duty to the 

daily activities of civilian life. During the last 3 FYs, the number of veterans receiving 

care in the Seamless Transition Program has increased (see table). 

Milwaukee VA’s Seamless Transition Report Summary 

Operation Enduring Freedom/Operation Iraqi Freedom Veterans 

FY 2004 FY 2005 FY 2006 

Active Duty 30 23 31 

Separated or 

In Transition 406 809 1,656 

Inpatient 25 41 99 

Outpatient 416 831 1,662 

Please note that the chart above tallies patient encounters, not “unique” patients and 

consequently, the numbers do not total. The medical center implemented the following 

initiatives: 

• A Seamless Transition Advisory Board was established to identify strategies for 

continued access to care and to improve care. 

• Social work and case management services were enhanced. 

• An outreach team was developed to provide education and support. 

• Brochures detailing all services available at the medical center were developed. 

• Provisions to offer comprehensive post-deployment mental health services were 

completed. 

Communication Strategies – Patient Satisfaction Strengthened 

In response to a VISN-identified focus on improving emotional support to patients, the 

medical center’s Customer Service Team developed two approaches to improve 

communication of important information to patients and family members. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

• White dry erase boards were installed in patients’ rooms. These white boards are 

used daily by staff to identify the names of patients’ physicians and nurses and to 

list daily appointments and activities. Currently, 80 patient care rooms are 

equipped with the white boards. Plans have been approved to purchase additional 

white boards for use in all patient rooms, except those on the locked mental health 

unit. The Customer Service Team conducted rounds and interviewed patients and 

their family members to assess responses to the use of the white boards. All 

expressed appreciation for staff efforts to keep them informed. 

• Blue discharge folders that contain basic information about the medical center, 

appropriate patient education materials specific to a patient’s condition, clinician 

provider contact information, and discharge information are provided to each 

patient upon admission as part of the discharge process. During the period of 

September 1–14, 2006, staff interviewed 116 of 333 discharged patients from 

three units regarding their blue discharge folders. Of those contacted, 104 (90 

percent) found the folder informative, useful, and helpful. 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Opportunities for Improvement 

Environment of Care – Environmental Deficiencies Needed To Be 

Corrected 

Conditions Needing Improvement. VA policy requires that the medical center be 

clean, sanitary, and maintained to optimize infection control and patient safety. We 

inspected four patient care units and found that they were clean and effectively 

maintained. Managers were responsive to concerns identified during the CAP review. 

We identified the following deficiencies that required management attention. 

Infection Control Concerns. Refrigerator and freezer temperatures must be monitored on 

a daily basis to ensure the integrity of medications or patient nourishments stored within 

them. We identified selected dates during November and December when temperatures 

were not recorded on the log sheets. 

Employees need to inspect patient care items regularly for damaged surfaces and either 

request repair or remove them from service when damage is noted. We observed a 

raised, cushioned commode seat that was torn and pillows on patient beds that were 

cracked. Additionally, raised, cushioned commode seats have seams that are problematic 

to clean. We recommended that managers either conduct training with housekeeping 

staff to ensure that commode seats are thoroughly cleaned or that they consider an 

alternative design with smooth surfaces. 

Emergency call system cords must be accessible and easily cleaned, as they are often 

located in shower areas and near commodes and sinks. The medical center generally 

used plastic cords; however, we observed rope-style emergency call system cords in 

patient showers and near one sink area. Rope-style cords are porous and cannot be easily 

cleaned. Additionally, we identified some cords that could not be accessed from floor 

level and others that were too long with the excess resting on the floor. 

During the previous CAP review inspection, dirty or worn gaskets were observed on 

some refrigerators and freezers. During the patient care unit inspections conducted for 

this CAP review, we identified two medication refrigerators with dirty or worn gaskets. 

Patient Privacy Concerns. The Health Insurance Portability and Accountability Act 

(HIPAA) of 1996 requires that patient health information be protected at all times from 

unauthorized access. We observed a document at a computer workstation in a hallway, 

documents that were in a plastic holder in a hallway outside a staff office, and clipboards 

hanging from handrails outside patient rooms. All of these documents contained 

sensitive patient information that could be accessed by unauthorized individuals. 

Safety Concerns. Unlocked dirty and clean supply utility rooms on patient care units 

could be accessed by unauthorized individuals. The utility rooms contained sharp items, 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

cleaning products, and other fluids that are drinkable that may cause injury. The clean 

supply utility rooms were vulnerable to tampering or theft. 

Patient medications must be secured at all times. We observed a medication cart in the 

hallway outside a patient room that was unlocked. The nurse was in the patient’s room, 

and the automatic-locking feature on the cart had malfunctioned. 

Cleaning products must be secured in patient care areas. A floor buffer with a bottle of 

cleaning product hanging from the handle was observed in a patient dining room. This 

item should have been appropriately stored and the cleaning product secured. 

A missing light cover over a sink in the locked mental health unit allowed access to the 

fluorescent bulbs, which could be removed and cause injury. 

A ceiling panel in the restroom of a seclusion room in the locked mental health unit was 

not flush to the ceiling, was accessible by standing on the commode, and could 

potentially be used as a ligature point.

Recommendation 1. We recommended that the VISN Director ensure that the Medical 

Center Director requires that the identified infection control, patient privacy, and safety 

concerns are corrected. 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and reported that they will continue environmental rounds and tracer activities and will 

correct all deficiencies identified during the review. Compliance will be monitored 

through ongoing inspections of patient care areas. The implementation plans are 

acceptable, and we will follow up on the planned actions until they are completed. 

Contract Community Nursing Home Program – Selected Program 

Aspects Required Improvement 

Conditions Needing Improvement. Veterans Health Administration (VHA) Handbook 

1143.21

 provides guidelines for the VA CNH Program, including oversight and 

monitoring of patients who are placed in CNHs by VA facilities. We visited VA patients 

in two CNH facilities and found they were receiving adequate care. Additionally, we 

interviewed administrators and nurse managers at both facilities, and they reported 

having a positive relationship and patient-centered communications with VA staff. We 

identified three CNH program aspects that required management attention. 

Oversight Committee. VA facilities are required to have a local oversight committee that 

monitors CNH program activities. This committee should meet quarterly, report to a 

chief clinical officer (Chief of Staff, Associate Director for Patient Care Services, or the 

equivalent), and include multidisciplinary management-level representatives from social 

 

1

 VHA Handbook 1143.2 is VHA Community Nursing Home Oversight Procedures, June 4, 2004. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

work, nursing, QM, acquisition, and the medical staff. The medical center did not have a 

CNH Oversight Committee. Annual CNH reports were forwarded to the Medical 

Executive Committee; however, this committee did not include the required membership. 

Annual Inspections. Inspection activities must reflect that the safety manager is involved 

in the annual inspection process for each CNH. We reviewed documentation of annual 

inspections conducted by the medical center’s CNH Inspection Team for five CNH 

facilities during the past 5 years. We found four instances in which there were 2-year 

lapses between safety inspections. 

Patient Monitoring. We reviewed the medical records of 10 VA patients who were 

placed in CNH facilities. Nine of the patients did not receive VA staff visits and/or 

monitoring, as required by VHA policy, specifically, there was a lack of documented 

visits or monitoring by a registered nurse. Managers needed to ensure that a nurse is 

consistently involved in follow-up care for the CNH patients who are in contract 

facilities. 

Recommendation 2. We recommended that the VISN Director ensure that the Medical 

Center Director requires that CNH program activities are monitored by a local CNH 

oversight committee with the required representation, annual CNH inspection activities 

are completed by each member of the CNH Inspection Team, and VA patients in CNH 

facilities receive VA staff visits and monitoring per policy. 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and reported that they will establish a local Community Based Programs Oversight 

Committee. This committee will monitor annual CNH inspections and follow-up visits 

of VA-placed patients. The implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Cardiac Catheterization Laboratory Standards – Informed Consent 

Process Needed To Be Improved and Clinical Providers Needed 

Current Cardiopulmonary Resuscitation Education 

Conditions Needing Improvement. The purpose of the review was to determine if the 

medical center’s cardiac catheterization laboratory practices were consistent with the 

American College of Cardiology/Society for Cardiac Angiography and Interventions 

Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards

published in 2001 and with VHA policy. These standards define requirements for 

clinical providers’ procedure volumes, laboratory procedure volumes, cardiac surgery 

resources, QM, the informed consent process, and CPR training. 

We reviewed a sample of 10 randomly selected patients’ records to determine the quality 

of the informed consent process, outcomes of the cardiac catheterization procedures, and 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

if applicable, availability of surgery. None of the 10 patients had complications or 

required surgery. We identified two areas that required management attention. 

Informed Consent. VHA policy requires that all practitioners who participate in cardiac 

catheterization procedures must be identified on the informed consent. Two informed 

consents listed names of attending physicians who did not perform the procedures. In 

addition, two informed consents only listed the counseling practitioner’s initials. 

Cardiopulmonary Resuscitation. VHA policy requires that all clinically active staff have 

current CPR education. There was no documentation of CPR education for two of four 

cardiac catheterization laboratory clinical providers during FY 2005. One provider was 

no longer employed by the medical center, and managers informed us that the remaining 

provider would be immediately scheduled for training. Contrary to VHA policy, the 

medical center’s CPR policy does not require clinically active staff to maintain current 

training. 

Recommendation 3. We recommended that the VISN Director ensure that the Medical 

Center Director requires that clinical providers complete informed consents for cardiac 

catheterization procedures that are consistent with VHA policy, all clinically active staff 

complete CPR education, and management officials review and revise the current CPR 

policy to clearly reflect VHA policy. 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and reported that they will provide education to cardiology staff and residents on the 

informed consent process. All credentialed and privileged staff will complete CPR 

education by January 15, 2007, and facility policy will be revised to reflect CPR 

expectations. The implementation plans are acceptable, and we will follow up on the 

planned actions until they are completed. 

Other Areas Reviewed 

Survey of Healthcare Experiences of Patients – Action Plan Was 

Implemented 

Veteran patient satisfaction surveying is designed to promote health care quality 

assessment and improvement strategies that address patients’ needs and concerns, as 

defined by patients. In 1995, VHA began surveying patients using a standardized 

instrument modeled from Picker Institute, a non-profit health care surveying group. 

Performance Measure 21 of the VHA Executive Career Field Performance Plan for 

FY 2006 states that in FY 2006, the percent of patients reporting overall satisfaction as 

Very Good or Excellent will meet or exceed targets for the performance period October 

2005–June 2006 as shown in the table below: 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Meets 

Target 

Exceeds 

Target 

Ambulatory Care 77% 80% 

Inpatients (Discharged 10/2004–6/2005) 76% 79% 

The following graphs show the medical center’s SHEP results for inpatients and 

outpatients: 

AccessCoordination of CareCourtesyEducation & InformationEmotional SupportFamily InvolvementPhysical ComfortPreferencesTransitionOverall Quality

National 81.31 78.63 89.95 68.02 65.80 75.85 83.41 74.49 70.03 **

VISN 81.00 77.10 89.30 66.90 64.40 75.80 85.10 73.20 70.10 **

Medical Center 81.80 78.00 92.30 70.10 67.70 77.40 86.70 77.70 74.30 ** Access Continuity of Care Courtesy Education & Information Emotional Support Overall Coordination Pharmacy Mailed Pharmacy Pick- upPreferences Specialist Care

Visit Coordination

National 80.9 77 94.6 72 83 75.1 81.1 64.4 81.3 80.5 84.1

VISN 81.8 72.3 94.2 70.8 82 73.2 83.1 65.8 81.2 79.1 85

Outpatient Clinics 85.7 76.3 95.8 73.3 82.9 73.8 89.3 77.2 83.9 81.2 83.6

 Inpatient SHEP Results

Outpatient SHEP Results

Legend: ** Less than 30 respondents 

The medical center’s inpatient SHEP scores were above the target score as defined by 

Performance Measure 21 in six of the nine dimensions reported and were significantly 

better than the national averages for five of those dimensions. Outpatient SHEP scores 

surpassed the target scores in 8 of 11 dimensions of care. SHEP results were discussed 

monthly at the Customer Service Council meetings. SHEP results were communicated to 

employees through town hall meetings, service-level meetings, and published minutes 

from the Customer Service Council meetings. Committee members regularly conducted 

customer service rounds on inpatient units to evaluate the consistency of use of white 

boards at the bedside and the effectiveness of communication following the placement of 

those white boards. To further enhance emotional support and patient education, patients 

receive their discharge information and instructions in a blue folder. Follow-up 

telephone calls to discharged patients regarding the helpfulness of these blue folders are 

now made 48 hours following discharge. Refer to the Organizational Strengths section 

for a discussion of white boards and blue folders. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Diabetes and Atypical Antipsychotic Medications – Patients Were 

Appropriately Screened and Managed 

The purpose of the review was to determine the effectiveness of diabetes screening, 

monitoring, and treatment of mental health patients receiving atypical antipsychotic 

medications (medications that cause fewer neurological side effects but increase the 

patient’s risk for the development of diabetes). 

VHA clinical practice guidelines for the management of diabetes suggest that: 

(a) diabetic patients’ hemoglobin A1c (HbA1c), which reflects the average blood glucose 

level over a period of time, should be less than 9 percent to avoid symptoms of 

hyperglycemia; (b) blood pressure should be less than or equal to 140/90 millimeters of 

mercury (mmHg); and (c) low density lipoprotein cholesterol (LDL-C) should be less 

than 120 milligrams per deciliter (mg/dL). 

To receive fully satisfactory ratings for these diabetes performance measures, the medical 

center must achieve the following scores: 

• HbA1c greater than 9 percent (poor glycemic control) – 15 percent of the patient 

population (lower percent is better) 

• Blood pressure less than or equal to 140/90mmHg – 75 percent of the patient 

population (higher percent is better) 

• LDL-C less than 120mg/dL – 79 percent of the patient population (higher percent is 

better) 

Although the medical center did not consistently meet VHA performance measures for 

HbA1c glycemic values, blood pressure monitoring, or cholesterol control for all 4 

quarters in FY 2006 (see charts on following two pages), clinical providers informed us 

that they immediately evaluate less than satisfactory scores through the Performance 

Monitoring Program (PMP). The PMP reviews 100 percent of primary care patients 

against selected performance measures. When less than satisfactory performance scores 

are achieved, interventions are immediately taken for corrective action. These 

interventions include, but are not limited to, provider feedback, staff education, and 

intense reviews of outliers. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Diabetes Detection and Management

HbA1c 

Clement J. Zablocki VA Medical Center 

11

13

14 14

16

14

0

10

12

19

14

16

0

5

10

15

20

25

30

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better FY 2006 Performance Measure Scores

Fully 

Satisfactory 

Score = 15

*Note: The medical center had no patients meeting the criteria for Qtr 1. 

Diabetes Detection and Management

B/P < 140/90

Clement J. Zablocki VA Medical Center

79 79

87

76 78

81

65

83

88 87

82

76

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better FY 2006 Performance Measure Scores

Fully 

Satisfactory 

Score = 75

Legend: < = Less than 

 B/P = blood pressure 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Diabetes Detection and Management

LDL-C < 120

Clement J. Zablocki VA Medical Center

81 83

87

78 78

81

85

75

88 87 85

78

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better FY 2006 Performance Measure Scores

Fully 

Satisfactory 

Score = 79

Legend: < = Less than 

VHA clinical practice guidelines for screening patients who are at risk for the 

development of diabetes suggest that fasting blood glucose (FBG) is the preferred 

screening test and should be performed every 1–3 years. A normal FBG is less than or 

equal to 110 mg/dL. Patients with FBG values of more than 110 mg/dL but less than 126 

mg/dL should be counseled about prevention strategies (calorie-restricted diets, weight 

control, and exercise). A FBG value of more than or equal to 126 mg/dL on at least two 

occasions is diagnostic for diabetes. 

We reviewed a sample of 13 patients who were on one or more atypical antipsychotic 

medications for at least 90 days in FY 2005. Three patients in the sample were diagnosed 

with diabetes. One of the diabetic patients had an HbA1c value greater than 7 percent. 

In response, a medication change was implemented for optimal glycemic control. 

Another diabetic patient had an elevated LDL-C level; however, medications have been 

prescribed, and the patient’s LDL-C level was improving. Of the 10 non-diabetic 

patients, appropriate education and screenings were documented in the medical records. 

Quality Management Program – Program Was Comprehensive and 

Effective 

To evaluate QM activities, we interviewed the medical center Director, Chief of Staff, 

Associate Director for Patient Care Services, and QM personnel, and we evaluated plans, 

policies, and other relevant documents. For the purpose of this review, we defined a 

comprehensive QM program as including the following areas: 

• QM and performance improvement committees, activities, and teams. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

• Patient safety functions (including healthcare failure mode and effects analyses, root 

cause analyses, aggregated reviews, and patient safety goals). 

• Risk management (including disclosure of adverse events and administrative 

investigations related to patient care). 

• Utilization management (including admission and continued stay appropriateness 

reviews). 

• Patient complaints management. 

• Medication management. 

• Medical record documentation reviews. 

• Blood and blood products usage reviews. 

• Operative and other invasive procedures reviews. 

• Reviews of patient outcomes of resuscitation efforts. 

• Restraint and seclusion usage reviews. 

• Advanced clinic access reviews. 

• Efficient patient flow reviews. 

We evaluated monitoring and improvement efforts in each of the program areas through a 

series of data management process steps. These steps were consistent with Joint 

Commission on the Accreditation of Healthcare Organizations (JCAHO) standards and 

included: 

• Identifying problems or potential improvements. 

• Gathering and critically analyzing the data. 

• Comparing the data analysis with established goals and benchmarks. 

• Identifying specific corrective actions when results do not meet goals. 

• Implementing and evaluating actions until the problems are resolved or the 

improvements are achieved. 

We also evaluated whether clinical managers appropriately used the results of quality 

monitoring in the medical staff reprivileging process, and we reviewed mortality analyses 

to determine the level of facility compliance with VHA guidance. 

We found that the QM program provided comprehensive oversight of the quality of care. 

Generally, when problems were identified, actions were taken and adequately evaluated. 

We found good senior management support and clinician participation. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI 

VA Community Based Outpatient Clinics – Patients Received the 

Same Standard of Primary Care and Mental Health Services at the 

Cleveland CBOC and Medical Center 

The purpose of the review was to assess the effectiveness of CBOC operations and VHA 

oversight to determine whether CBOCs are in compliance with selected standards of 

operations, such as patient safety, QM, credentialing and privileging, and the emergency 

management plan. 

We interviewed key employees at the medical center and at the Cleveland CBOC and 

reviewed documentation and self-assessment tools on descriptions of services provided, 

including warfarin2

 clinic services. We determined that the medical center and the 

CBOC warfarin clinics were both managed by a pharmacist, with primary care physician 

oversight, and maintained the same standards and expectations. Patients received 

education from a pharmacist before they received their first dose of warfarin. Patients’ 

laboratory values and follow-up care were managed by a pharmacist, with primary care 

physician oversight. Patients received a handbook with a toll-free telephone number to 

help facilitate prompt reporting of new medications or other vital information. 

The CBOC environment of care inspection revealed a clean facility that met JCAHO, 

HIPAA, and Life Safety Code requirements. The emergency management plan was 

current, and all clinical providers were educated in and knowledgeable about rendering 

emergency care to veterans. All clinical providers were certified in CPR. The automated 

electronic defibrillator was inspected, and functionality documentation was up to date. A 

review of three CBOC clinical providers’ credentialing and privileging files and two 

CBOC nurses’ official personnel folders showed that appropriate background screenings 

were completed. 

 

2

 Medication used to prevent blood clots. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: December 26, 2006 

From: Network Director, VISN 12 (10N12) 

Subject: Combined Assessment Program Review of the 

Clement J. Zablocki VA Medical Center, Milwaukee, 

Wisconsin

To: Director, Chicago Office of Healthcare Inspections, Office 

of Inspector General (54CH) 

Attached please find the Combined Assessment Program 

Review response from VAMC Milwaukee. If anything 

additional is needed, please contact my office at (708) 

202-8400. Thank you. 

James W. Roseborough 

VA Office of Inspector General 15 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: December 26, 2006 

From: Medical Center Director (695/00) 

Subject: Combined Assessment Program Review of the 

Clement J. Zablocki VA Medical Center, Milwaukee, 

Wisconsin

To: Director, Chicago Office of Healthcare Inspections, Office 

of Inspector General (54CH) 

Attached please find the Combined Assessment Program 

Review from VAMC Milwaukee. If additional 

information is needed, please contact my office at (414) 

384-5314. Thank you. 

/s/ 

Glen W. Grippen 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

 

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response 

to the recommendations in the Office of Inspector General 

Report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN 

Director ensure that the Medical Center Director requires that 

the identified infection control, patient privacy, and safety 

concerns are corrected. 

Concur Target Completion Date: 3/31/07 – 10/1/07 

a. Review refrigerator and freezer monitoring process. The 

facility will continue with environmental rounds and tracer 

activity to identify focus areas and provide immediate follow 

up. Facilities Management (FM) will install wireless 

temperature recording and alarming system. Both Nursing 

and FM will be expected to respond to alarms. Contract 

awarded 10/1/06. All units except Spinal Cord Injury (SCI) 

and Nursing Home Care Unit (NHCU) will be done 3/31/07; 

SCI and NHCU will be done 10/1/07. 

b. Determine process for inspecting, repairing and/or cleaning 

patient care items with damaged surfaces. FM will replace 

torn commode seat by 1/15/07. FM will provide staff followup training on cleaning techniques by 12/31/06. SCI will 

review products that may be easier to clean. Review will be 

completed by 12/31/06. FM has replaced cracked pillow. 

Patient care items will be reviewed during environmental 

rounds and tracer activities (ongoing). 

c. Eliminate rope-style emergency call system cords and 

assure that emergency call cords can be reached from floor 

level. FM will replace all porous pull cords with non-porous 

pull cords, and adjust to appropriate length by 1/31/07. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

d. Monitor and clean patient food or medication refrigerator 

gaskets. The dirty or worn gaskets on the two patient 

medication refrigerators noted during the review have been 

cleaned and replaced. Issue will continue to be monitored 

and tracked during environmental rounds and tracer activities. 

Findings (if any) will be shared immediately with area 

leadership for follow up. 

e. Review practice of placing potentially sensitive 

information near computer workstations, outside patient 

rooms, and in hallways outside offices. The Information 

Security Officer (ISO) will provide follow-up training to staff 

in patient care areas regarding computer information security 

by 1/31/07. ISO will review local policy on information 

security and on time-out of computers by 1/31/07. Nurse 

Managers of patient care areas will review clip boards to 

ensure they do not contain patient sensitive information by 

1/1/07. This information will be validated during ongoing 

environmental rounds and tracers. 

f. Secure (lock) clean and dirty utility rooms. FM will install 

locks on clean and dirty utility room doors (where needed) by 

3/31/07. 

g. Monitor security of medical carts. Medication carts are 

self-locking. One was found to be malfunctioning during 

review. Nursing will check all medication carts for 

appropriate functioning of locking mechanism by 1/31/07. 

Work area sweeps during environmental rounds and tracers 

will be ongoing. 

h. Monitor security of cleaning supplies. FM has retrained 

housekeeping staff. NHCU managers and FM will continue 

to monitor staff performance (ongoing). 

i. Assess Inpatient Mental Health Environment for potential 

risks. FM will replace light cover by 12/31/06. FM will fix 

ceiling panel so it is flush with ceiling by 1/15/07.

Recommendation 2. We recommended that the VISN 

Director ensure that the Medical Center Director requires 

that: (a) CNH program activities are monitored by a local 

CNH oversight committee with the 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

required representation, (b) annual CNH inspection activities 

are completed by each member of the CNH Inspection Team, 

and (c) VA patients in CNH facilities receive VA staff visits 

and monitoring per policy. 

Concur Target Completion Date: 1/31/07 

a. Review and revise CNH Program Oversight Committee 

structure, annual inspection process and patient monitoring. 

VA Milwaukee will establish a local Community Based 

Programs Oversight Committee. This committee will be 

responsible for monitoring and reviewing all community 

based programs and related contacts requiring oversight as 

defined in the respective handbooks, including: Contract 

Nursing Home Care (CNHC), Purchased Home health 

Services/Homemaker Home Health Aide, Home Infusion, and 

Contract Adult Day Health Care (CADHC). This committee 

would also oversee progress towards community-based 

program performance measures, including Care 

Coordination/Home Telehealth, and Non-Institutional Care 

Workload. Committee membership would include 

multidisciplinary management-level representatives from 

social work, nursing, quality management, acquisitions, 

medical staff, and other key staff subject experts. The 

committee will meet at least quarterly, and will report to the 

Chief of Staff and Associate Director for Patient Care 

Services through the Medical Executive Committee. 

Completion date 1/31/07. 

b. The full CNHC Inspection Team will meet at least monthly 

to complete the document-based review process and 

determine if designated facilities are in compliance with VA 

standards. All members will be expected to complete their 

portion of the review process in sequence with the full 

inspection team. Compliance with the review process will be 

monitored by the Community Based Program Manager, and 

will be reported to the Oversight Committee. Members who 

fail to complete their portion of the review process in a timely 

manner will be reported to their immediate supervisor for 

corrective action. Completion date 1/31/07. 

VA Office of Inspector General 19 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

c. Patients in contact nursing homes will receive follow-up 

visits in accordance with VHA Handbook 1143.2. The 

Community Based Program Manager will monitor 

completion of monthly visits and related documentation using 

a tracking tool. Monthly visits will be alternated between a 

social worker and a nurse, unless otherwise indicated in the 

patient’s visit plan. Patients who meet Handbook criteria for 

less frequent visits will be identified in the tracking tool and 

will have appropriate care planning documentation in the 

medical record. Compliance with monthly follow-up visits 

will be reported on a quarterly basis to the Community Based 

Programs Oversight Committee. Completion date 1/31/07.

Recommendation 3. We recommended that the VISN 

Director ensure that the Medical Center Director requires 

that: (a) clinical providers complete informed consents for 

cardiac catheterization procedures that are consistent with 

VHA policy, (b) all clinically active staff complete CPR 

education, and (c) management officials review and revise the 

current CPR policy to clearly reflect VHA policy.

Concur Target Completion Date: 1/31/07 

a. Review process of informed consent for cardiac 

catheterization procedures. Chief of Staff will provide 

education to each cardiologist and cardiology resident 

regarding their responsibilities in obtaining and documenting 

informed consent. Monthly review of compliance with policy 

will occur on a random sample of consents until 100 percent 

compliance with documentation requirements is met. Chief 

of Staff will issue a Chief of Staff Information Bulletin to all 

clinical staff providing refresher education about their 

responsibilities of clinicians in obtaining and documenting 

consent by 1/31/07. 

b. Provide education to all clinically active staff. All 

credentialed and privileged staff received cardiopulmonary 

resuscitation education packets during the week 

December 11, 2006. Individuals are expected to complete 

their education before January 15, 2007. The Chief of Staff 

Office is coordinating this effort, tracking compliance and 

will follow up to completion. 

VA Office of Inspector General 20 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

c. Review and revise current CPR policy to clearly reflect 

VHA policy. Chief of Staff Office is currently working to 

revise facility policy for discussion at Medical Executive 

Committee in January 2007. Anticipate publication prior to 

1/31/07. 

VA Office of Inspector General 21 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Verena Briley-Hudson 

Director, Chicago Office of Healthcare Inspections 

(708) 202-2672 

Acknowledgments John Brooks 

Judy Brown 

Paula Chapman 

Wachita Haywood 

Jennifer Reed 

Leslie Rogers 

VA Office of Inspector General 22 
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, WI

 Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 12 (10N12) 

Director, Clement J. Zablocki VA Medical Center (695/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Russell D. Feingold and Herb Kohl 

U.S. House of Representatives: Steve Kagen, Gwen Moore, Thomas Petri, and Paul Ryan 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 23