Report Summary

Title: Healthcare Inspection – Evaluation of System-Wide Clinical, Supervisory, and Administrative Practices, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
Report Number: 16-02676-13 Download
Issue Date: 11/2/2017
City/State: Oklahoma City, OK
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection Report
Release Type: Unrestricted

OIG conducted an inspection in response to Senator James Inhofe’s request to evaluate clinical, supervisory, and administrative practices at the Oklahoma City VA Health Care System (System), Oklahoma City, OK. We also evaluated the System Director’s concerns and coordinated parts of this review with The Joint Commission. Our comprehensive review identified multiple program areas, processes, and operations needing improvement. The root cause for many of these issues was poor and unstable leadership at a number of levels, most notably in the Director position. Without strong and effective leadership, an inattentive and apathetic organizational culture evolved that allowed problems to arise and persist. It was only after new leadership was installed in May 2016 that the culture improved and necessary changes took place. We made 24 recommendations.