Review of System and Veterans Integrated Service Network 7 Leaders’ Effectiveness in Resolving Operational and Leadership Challenges at the VA Dublin Healthcare System in Georgia

The VA Office of Inspector General (OIG) conducted an inspection to evaluate the Veterans Integrated Service Network (VISN) 7 leaders’ effectiveness in identifying and resolving concerns regarding the VA Dublin Healthcare System’s (system’s) leadership and operational challenges. 

The OIG determined VISN leaders engaged with system leaders and identified clinical vulnerabilities and operational deficiencies during 2022 and 2023 VISN site visits but did not hold system leaders accountable for resolving the issues. Not providing continued oversight contributed to prolonged unsafe clinical practices later identified by Veterans Health Administration’s (VHA’s) Office of Nursing Service in June 2024, that led to the curtailment of patient admissions to the community living center, domiciliary, and inpatient acute care units.

The OIG found VHA has not clearly established VISN leaders’ roles, responsibilities, and authorities in a manner that empowers VISN leaders to provide proactive oversight and hold system leaders accountable for promptly addressing and resolving deficiencies. These shortcomings likely contributed to VISN executive leaders’ passive oversight. At the time of the publication of this report, VHA announced significant changes in VHA’s management structure.

As of December 2024, the system’s units were open for patient admissions and services. On November 2, 2025, a new System Director was permanently appointed; however, remaining members of the executive leadership team are either acting or interim leaders. 

The OIG made one recommendation to the Under Secretary for Health related to standardizing the VISN Chief Medical Officer and Chief Nursing Officer roles and responsibilities, and two recommendations to the VISN Network Director related to providing sustained system support and resolution of identified deficiencies. The Acting Under Secretary for Health concurred in principle and the VISN Director concurred with and provided action plans to address the OIG’s recommendations. The OIG considers the recommendation to the Under Secretary for Health closed at publication.