Fayetteville VA Staff Hesitated to Report Patient-Safety Concerns Over Fear of Retaliation, OIG Found
By VA Headlines staff · Published Nov 13, 2026 · Source dated November 13, 2026 (VA Office of Inspector General)
The VA Office of Inspector General (OIG) found that inconsistent supervisory practices, fear of retaliation, and limited psychological safety across services led employees at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, to hesitate to report patient-safety concerns, which increased the risk that issues would remain unreported. That finding did not align with VHA Directive 1050.01(1), which requires an environment where employees feel safe to report patient-safety concerns. Inspectors also found that over half of primary care panel sizes exceeded requirements. OIG published healthcare facility inspection 26-00060-15 on November 13, 2026, and made 4 recommendations. The VISN Director and facility Director concurred. OIG considers recommendations 2 and 3 closed; recommendations 1 and 4 remain open.
The inspection
OIG inspected the mid-high-complexity facility from May 19 through 21, 2026. In fiscal year 2025, the system provided direct care to about 60,000 patients. The evaluation covered five domains: culture, environment of care, patient safety, integrated veteran care, and the veteran-centered safety net. OIG made no recommendations on environment of care or the veteran-centered safety net.
Culture: fear of retaliation and hesitation to report
On culture, OIG found that inconsistent supervisory practices, fear of retaliation, and limited psychological safety across services led employees to hesitate to report patient-safety concerns. OIG did not find that staff were retaliated against; its words are "fear of retaliation" and that employees hesitated to report.
Recommendation 1 asks the Executive Director 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 VHA Directive 1050.01(1). The facility concurred. Target date: April 30, 2027. Open.
Patient safety: test-result policy and workflows
Inspectors also reviewed processes to communicate test results. Those reviews produced two recommendations, both of which OIG closed before publication, based on evidence that leaders had completed improvement actions.
Recommendation 2: The Executive Director takes appropriate steps to update the facility's policy for communicating test results, as required by VHA Directive 1088(1). Closed.
Recommendation 3: The Chief of Staff and Associate Director for Patient Care Services take appropriate steps to develop written workflows consistent with that directive. Closed.
Primary care panels over capacity
On integrated veteran care, inspectors found that over half of primary care panel sizes exceeded requirements in VHA Directive 1406(3). Facility targets were 1,200 patients for physicians and 900 for nonphysician providers. At the time of the May 2026 inspection, the supervisory administrative officer reported that 59 percent of physicians' and 58 percent of nurse practitioners' panels were above 100 percent capacity, and 24 of 51 panels (47 percent) exceeded 105 percent capacity. The coordinator and chief explained that physician departures led staff to move patients to other providers, which increased panel sizes. OIG also noted that assigning full panels to new providers caused them to exceed baseline capacity limits in the directive, which states that new providers may be set at 50 percent capacity for the first 6 months and reach 100 percent at 12 months. Panel sizes over baseline capacity, OIG said, can lead to staff burnout and reduce the quality of patient care by making it harder for patients to get timely, thorough, and consistent services.
Recommendation 4: The Executive Director takes appropriate steps to manage primary care teams' panel sizes, in accordance with VHA Directive 1406(3). The facility concurred. Target date: February 26, 2027. Open.
The report is a facility-culture and panel-size inspection. It does not allege misconduct by a named employee.
Related: Only 3 of 28 VA facilities without locked mental health units had required involuntary-admission agreements. Temple VA: no process to correct missed test-result notices due within seven days. Marion VA: 2 patient-safety recommendations on test-result policy. VA OIG hospital inspections. Department of Veterans Affairs (VA) News. More: all VA Headlines reports. How we report: Methodology & Corrections.
Healthcare Facility Inspection of the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas - Report 26-00060-15, November 13, 2026
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