Report Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a descriptive evaluation of VHA facilities’ leadership and organizational risks. The report focuses on executive leadership position stability and engagement, budget and operations, staffing, employee satisfaction, patient experience, accreditation surveys and oversight inspections, factors related to possible lapses in care, and VHA performance data.

This report describes observations from healthcare inspections performed at 45 VHA medical facilities from November 30, 2020, through August 23, 2021. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2021 OIG reviews.

The OIG did not issue recommendations but developed this summary report for the Under Secretary for Health, Veterans Integrated Service Network directors, and facility senior leaders to consider when improving operations and clinical care at VHA facilities.