Healthcare Facility Inspection of the VA Milwaukee Healthcare System in Wisconsin

Report Information

Issue Date
Closure Date
Report Number
25-00249-275
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 Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
1
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 VA Milwaukee Healthcare System in Wisconsin.

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

The OIG made one recommendation 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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2026

The Director takes appropriate action so leaders update their local policy and develop service-level workflows for test result communications, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.