Healthcare Facility Inspection of the VA Phoenix Health Care System in Arizona

VA Office of Inspector General · Report 26-00041-05 · October 19, 2026 · Office of Healthcare Inspections

What the OIG found

The OIG conducted a focused inspection of care at the VA Phoenix Health Care System in Arizona, evaluating culture, environment of care, patient safety, integrated veteran care, and the veteran-centered safety net. A single issue required correction, in the patient safety domain. The OIG made one recommendation: that the Chief of Staff and the Associate Director for Patient Care Services develop written service-level workflows defining staff members’ roles in communicating test results to patients, as required by VHA Directive 1088(1).

Who it concerns

VA Phoenix Health Care System in Arizona

Why it matters to a family

When a family is waiting on a test result to know what happens next, a facility needs a written, staff-wide process for delivering that result; this inspection found Phoenix had not documented those service-level workflows.

The official report

The OIG’s report page · Full report (PDF)

Summary ours; the report is the OIG’s. Read it at vaoig.gov →