Healthcare Facility Inspection of the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas

Report Information

Issue Date
Report Number
26-00060-15
VISN
4
State
Arkansas
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 Care Services Operations
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
4
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 Veterans Health Care System of the Ozarks in Fayetteville, Arkansas.

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

The OIG made four recommendations for VA to correct identified issues in three domains: 
     •    Culture 
       o    Psychological safety 
     •    Patient safety 
       o    Facility policy for the communication of test results 
       o    Service-level workflows for the communication of test results 
     •    Integrated veteran care 
       o    Primary care panel sizes
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Director takes appropriate steps to implement a data‑driven strategy to measure and improve psychological safety across services, with a focus on alleviating employees’ fear of retaliation and strengthening their confidence in reporting patient safety concerns, in alignment with Veterans Health Administration Directive 1050.01(1), Veterans Health Administration Quality and Patient Safety Programs.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2026

The Executive Director takes appropriate steps to update the facility’s policy for communicating test results, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2026

The Chief of Staff and Associate Director for Patient Care Services take appropriate steps to develop written workflows, consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Director takes appropriate steps to manage primary care teams’ panel sizes, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.