All GAO report sources are currently available (See reports below). Per the below OIG notification, the OIG website is temporarily unavailable. Will update once it's back live.
REPORTS LIBRARY
VA Oversight Reports: The Evidence Behind the Bills
GAO & VA OIG reports (2015–2025). Tap a category to filter. Newest → oldest.
Tip: Multi-select filters (e.g., Data + Staffing). Tap “All” to reset.
| Year | Report # | Title | Summary | Source | Tags |
|---|---|---|---|---|---|
| 2025 | GAO-25-106874 | Electronic Health Records: VA Making Incremental Improvements in New System but Needs Updated Cost Estimate and Schedule | VA still lacks full life-cycle cost/schedule and defined performance targets for its EHR. | Source | Data Culture |
| 2025 | GAO-25-108071 | Priority Open Recommendations: Department of Veterans Affairs | GAO flags unimplemented, high-impact fixes (access, scheduling, EHR cost/schedule). | Source | Data Culture |
| 2025 | GAO-25-108739 | Veterans Affairs: Key AI Practices Could Help Address Management Challenges | Weak IT governance & monitoring undermine reliability of AI-related reporting. | Source | Data Culture |
| 2024 | GAO-24-105308 | Veterans Community Care Program: VA Needs to Improve Timeliness Metrics and Data Reliability | Timeliness metrics based on unreliable data across facilities. | Source | Data |
| 2023 | GAO-23-106731 | Electronic Health Records: VA Needs to Address System Issues and Assess Satisfaction | Deployments paused; lack of independent assessment; user dissatisfaction risks data quality. | Source | Data |
| 2023 | GAO-23-105617 | VA Actions Needed to Ensure Timely Scheduling of Specialty Care | Incomplete enterprise analysis of timeliness data; GAO urges comprehensive review. | Source | Data |
| 2023 | OIG 23-00924-186 | Community Care Departments Need Reliable Staffing Data to Inform Workforce Decisions | Inconsistent org codes & unverified inputs distort staffing metrics used for access decisions. | Source | Data Staffing |
| 2022 | GAO-22-103718 | Electronic Health Records: VA Needs to Address Data Management Challenges for New System | Data migration/quality weaknesses threaten care and reporting; governance gaps flagged. | Source | Data |
| 2022 | OIG 21-01361-192 | The Compensation Service Could Better Use Special-Focused Reviews to Improve Claims Processing | Internal-control weaknesses in oversight reviews; lacked root-cause analysis. | Source | Data Culture |
| 2016 | GAO-16-373 | Veterans Crisis Line: Additional Testing, Monitoring, and Information Needed to Ensure Better Quality Service | Missing KPI targets/monitoring; testing gaps led to unreliable performance reporting. | Source | Data Culture |
| 2016 | GAO-16-328 | VA Health Care: Actions Needed to Improve Newly Enrolled Veterans’ Access to Primary Care | Scheduling data weaknesses masked true wait times. | Source | Data |
| 2023 | OIG 23-00853-160 | OIG Determination of VHA’s Occupational Staffing Shortages, FY 2023 | 3,118 severe shortages across 282 occupations—widespread shortfalls. | Source | Staffing Culture |
| 2023 | GAO-23-106836 | Veterans Health Care: Staffing Challenges and Ongoing Efforts | GAO testimony summarizing staffing findings & open recommendations. | Source | Staffing |
| 2023 | GAO-23-105706 | VHA Lacks Reliable Onboarding Data for New Clinical Staff | USA Staffing data incomplete/inaccurate/untimely; weak pipeline visibility. | Source | Staffing Data |
| 2022 | GAO-23-105372 | Staffing Challenges Persist for Integrating Mental Health into Primary Care | Most facilities cited staffing as top barrier; follow-through not monitored. | Source | Staffing Culture |
| 2022 | OIG 21-03349-186 | Multiple Failures in Test Results Follow-up … Hampton VA | Patient-safety breakdown from process/staffing failures; delayed peer reviews. | Source | Staffing Culture |
| 2020 | OIG 19-00007-170 | Inadequate Inpatient Psychiatry Staffing and Related Concerns | Below-expected staffing; absence of staffing guidelines impeded accountability. | Source | Staffing |
| 2019 | OIG 18-01693-196 | OIG Determination of VHA’s Occupational Staffing Shortages, FY 2019 | 96% of facilities reported at least one severe shortage; Medical Officer & Nurse lead. | Source | Staffing |
| 2018 | OIG 18-01693-780 | OIG Determination of VHA’s Occupational Staffing Shortages, FY 2018 | First year listing per-facility shortages under the Choice & Quality Employment Act. | Source | Staffing |
| 2018 | OIG 16-04655-70 | Audit of VISN 7 Power Wheelchair and Scooter Repairs | Avg 69-day repair delays; missing policies/monitoring hurt access. | Source | Staffing Culture |
| 2015 | OIG 15-03063-511 | OIG Determination of VHA’s Occupational Staffing Shortages | Baseline snapshot of widespread shortages post-2014 scandal. | Source | Staffing |
| 2025 | GAO-25-107963 | Veterans Affairs: Action Needed to Address Continuing IT Management Challenges | Persistent governance failures across major IT programs; many open GAO recs. | Source | Culture Data |
| 2024 | GAO-25-106969 | Additional Actions Needed to Improve VHA Internal Oversight and Risk Management | Define internal audit’s purpose & align risk management with leading practices. | Source | Culture |
| 2023 | OIG 22-01253-164 | Failure of Leaders to Address Safety, Staffing, and Security … Tuscaloosa VAMC | Leaders ignored a prior safety recommendation; key vacancies persisted. | Source | Culture Staffing |
| 2021 | GAO-21-254 | Freedom of Information Act: Actions Needed to Improve Agency Compliance with Proactive Disclosure Requirements | Calls for stronger tracking/reporting of proactive disclosures (incl. VHA). | Source | Culture |
| 2019 | OIG 18-01010-95 | Failures Implementing Aspects of the VA Accountability and Whistleblower Protection Act of 2017 (OAWP) | Missteps undermined whistleblower protections and accountability. | Source | Culture |
| 2019 | OIG 17-05909-111 | Mismanagement of the VA Executive Protection Division | No policies, poor assessments, and abuses since at least 2015. | Source | Culture |
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