Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
Report Number: 18-01147-47 Download
Report
Issue Date: 12/20/2018
City/State: Janesville, WI
Baraboo, WI
Beaver Dam, WI
Freeport, IL
Madison, WI
Rockford, IL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted
Summary:

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the William S. Middleton Memorial Veterans Hospital. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results; and High-risk Processes: Central Line-associated Bloodstream Infections.

The Facility had stable executive leadership and active engagement with employees and patients. The OIG reviewed accreditation agency findings, adverse events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors.

The OIG noted findings in two of the eight areas reviewed and issued four recommendations attributable to the Director and the Chief of Staff. The identified areas with deficiencies are:

(1) Credentialing and Privileging

• Focused and Ongoing Professional Practice Evaluation processes

(2) Medication Management: CS Inspection Program

• CS Inspectors free of conflicts of interest

• Reconciliation of CS return to stock

• Verification of drugs held for destruction