Oversight of hospital data reporting, inspections, and complaints

July 2024

Zane Potter, Team Lead
Stephanie Hoffman, Deputy Legislative Auditor | Eric Thomas, Legislative Auditor

Hospitals report information to state and federal agencies

The Department of Health (DOH) licenses and regulates 103 hospitals in Washington. Hospitals must report certain information to DOH and federal agencies, such as the following.

1. Financial Data: Revenues, expenses, billed charges, employee compensation, facility fees.
2. Patient Discharge Data: Race, ethnicity, gender identity, sexual orientation, preferred language if reported by the patient.
3. Charity Care Data: Financial assistance applications submitted, completed, and approved.
4. Adverse Health Events: Surgical, care management, environmental, and radiologic events.
5. Community Health Needs: Activities related to improving community health.

DOH must inspect hospitals to evaluate whether they comply with state and federal laws and regulations related to patient safety risks. By law, DOH also must investigate any reported concerns or complaints related to patient care.

Study scope

The 2022 Legislature directed JLARC to assess DOH's oversight of hospital data reporting, inspections, and complaints (2022 Supplemental Operating Budget, ESSB 5693, Section 103).

This study will focus on the information that hospitals must report to DOH and federal agencies in the five categories above. It will consider how DOH analyzes and uses the information.

The study also will examine DOH's processes for conducting hospital inspections, investigating complaints, and ensuring that hospitals resolve issues.

This study will address the following questions

Study questions reflect preliminary outreach, research, and analysis of potential racial equity considerations per RCW 44.28.076.

1. What financial, patient discharge, charity care, adverse health events, and community health needs information must hospitals report to DOH or federal agencies?
2. How does DOH analyze and use the reported information?
3. What type of inspections does DOH conduct, and how often are they done? How does DOH ensure that hospitals correct deficiencies?
4. Are DOH's processes for receiving, investigating, and ensuring resolution of complaints efficient and effective?
   1. What approaches does DOH use to provide culturally responsive materials and interactions with consumers who file complaints?

What's next

• Preliminary Report: July 2025
• Proposed Final Report: September 2025

Study team

Zane Potter, Team Lead, (360) 786-5293
Ashley Trunnell, Research Analyst, (360) 786-5181