Oversight of Hospital Data Reporting, Inspections, and Complaints

The Legislature should consider specifying the maximum amount of time allowed between acute care hospital inspections and clarify the basis for calculating the 18-month average.

RCW 70.41.120 requires DOH to inspect hospitals "on average at least every eighteen months." Statute does not specify the maximum time that can pass between inspections. It also does not specify how many years or inspections should be included when calculating the average. This can lead to significant variation.

Legislation required: Yes

Fiscal impact: Depends on legislation

Implementation date: At the Legislature's discretion.

DOH should meet the timeline in statute for all hospital inspections and report its performance to the Legislature.

DOH should develop a plan for completing inspections that includes a staffing analysis and benchmarks to show whether it is on track for meeting annual goals. The plan should reflect how the department will adjust for workload changes.

DOH should annually update JLARC and the appropriate legislative policy committees about the percent of all acute care and behavioral health hospital inspections completed on time.

Legislation required: None

Fiscal impact: None

Implementation date: July 2026

Agency response: DOH concurs.

DOH should verify accrediting organization standards for hospital inspections and enforce the requirement for hospitals to submit proof of inspections.

Statute (RCW 70.41.122) allows a hospital to use an accrediting organization inspection in lieu of a state inspection once every 36 months if two conditions are met:

• DOH verifies that the accrediting organization's inspection standards are "substantially equivalent" to state requirements.
• The hospital gives DOH "documentary evidence" that it passed inspection.

DOH counts the inspections but has not verified that standards are "substantially equivalent" and does not receive documents from all hospitals.

Legislation required: None

Fiscal impact: None

Implementation date: July 2026

Agency response: DOH concurs.

DOH should assess whether language access barriers exist that may limit use of its complaint system.

This should include:

• Evaluating how easily users can find and use translated complaint materials.
• Gathering input from limited English proficiency communities and organizations on barriers they may face.
• Determining the extent to which language assistance is available throughout the complaint process.
• Benchmarking practices against other states.
• Assessing whether other cultural factors may prevent individuals from filing complaints.

DOH should address any barriers that it identifies.

Legislation required: None

Fiscal impact: None

Implementation Date: July 2026

Agency response: DOH concurs.

DOH should review hospitals' plans to address adverse health events and provide feedback to hospitals to help prevent the reoccurrence of these events.

The legislative intent for this reporting requirement was to facilitate quality improvement in the health care system. Reviewing this information could allow DOH to identify common problems among hospitals and inform its prevention and education efforts.

Legislation required: None

Fiscal impact: DOH's 2020 budget request indicated a cost of $295,000 and 1.4 FTE per fiscal year.

Implementation date: December 2027. This allows time for budget requests and staff hiring.

Agency response: DOH concurs.

DOH should make reported hospital data more accessible to the public.

DOH should work with stakeholders to identify key data and the level of detail needed for public reporting. It also should adopt best practices for online reporting, such as offering interactive datasets and compiling data for easy comparison.

DOH received one-time funding for a staff person to do this work. DOH filled the position in February 2025 and funding expires in June 2025.

Legislation required: None

Fiscal impact: DOH should be able to do some of this work within existing resources. If DOH needs additional resources to complete the work, it should include that information in its future budget requests.

Implementation date: July 2026

Agency response: DOH concurs.