OKLAHOMA CITY — The Oklahoma City VA Health Care System has suffered from the lack of stable, permanent leadership and basic elements of patient safety programs that have not been consistently completed as required, according to a health care inspection of the facility released Thursday.

The inspection, conducted by the U.S. Department of Veterans Affairs’ Office of Inspector General at the request of Oklahoma U.S. Sen. Jim Inhofe, evaluated clinical, supervisory and administrative practices at the facility, which serves veterans in 48 counties in Oklahoma as well as two counties in north central Texas and includes the Oklahoma City VA Medical Center.

“Today’s report is a step in the right direction, but we must do more to provide Oklahoma veterans with the quality of health care they deserve. That starts by using outside oversight to hold VA facilities to the same standards as private hospitals,” Inhofe said in a statement.

The report stated that between April 2012 and November 2014, the Oklahoma City facility had five acting or permanent director and that, beginning in December 2014, the associate director served as system director for about 18 months.

“We found that the lack of a stable, permanent system director contributed to a weakened organizational environment, as did the leadership and management approaches of other senior leaders,” the report said. A permanent director has been in place since May 2016, the report said.

The report also cited inadequate staffing of nurses with about 87 percent of the authorized number of registered nursing positions were filled, but noting that recruiting and retention programs have been implemented.

It also said that while most of the health care system’s patient safety programs were effective, assessments of the root cause and other details of patient conditions did not consistently comply with the agency’s requirements.

In addition, steps were not in place to inform a patient or a patient’s family when poor outcomes occur due to a system or provider error, according to the report, that unauthorized use of the system’s computerized patient record system was found and the emergency departments were falling short of goals.

“The ED (emergency department) was not meeting several performance measures including timeliness of care, and patients leaving without being seen,” the report said.

The report added that 7.5 percent of patients left the emergency department without being seen in fiscal year 2015, and 5.8 percent in FY 2016.

The VHA target for patients who leave before being seen is less than 2 percent, but no greater than 4 percent.

It also said that while most of the health care system’s patient safety programs were effective, assessments of the root cause and other details of patient conditions did not consistently comply with the agency’s requirements.

In addition, steps were not in place to inform a patient or a patient’s family when poor outcomes occur due to a system or provider error, according to the report.