JLARC finds Washington Department of Health late on many hospital inspections and not reviewing adverse‑event corrective plans

A Joint Legislative Audit and Review Committee preliminary report presented May 14 found shortcomings in the Department of Health’s oversight of hospital inspections, complaint investigations and hospital data reporting that limit the agency’s ability to ensure patient safety.

JLARC staff Zane Potter and Ashley Tranel told the committee that DOH did not complete many inspections on time, does not verify whether standards used by third‑party accrediting organizations are substantially equivalent to state requirements, and does not review hospitals’ corrective plans for reported adverse health events as state law authorizes.

Key findings presented to the committee included: • Washington has 103 hospitals that fall under DOH oversight, including 93 acute care hospitals and a small number of behavioral health hospitals; those hospitals served about 721,000 patients in 2023. • DOH was late with 72% of acute care hospital inspections as of December 2024. JLARC provided a breakdown: about 8% of hospitals were less than 30 days overdue, 17% were 30 days to 6 months overdue, 39% were 6 months to 1 year overdue, 9% were more than 1 year overdue, and 28% were inspected on time. • State law permits DOH to accept inspections from authorized accrediting organizations in lieu of a DOH inspection every 36 months, but JLARC found DOH has not verified that accreditor standards are substantially equivalent to state requirements and that hospitals often do not submit proof that they passed the accreditor inspection. • Reported adverse health events in hospitals rose by 84% from 2016 to 2023 (from 628 to 1,153). JLARC found DOH does not review hospital corrective plans for these events, although state law requires DOH review “as it deems necessary.” About 62% of reported events included a corrective plan. • DOH posts hospital data online but provides limited analysis or accessible comparative displays; consumers must download year‑by‑year files to compare hospitals.

JLARC recommended the legislature consider specifying a maximum time allowed between acute care hospital inspections and clarify how the required 18‑month average should be calculated. The legislative auditor also recommended DOH do the following: meet statutory timelines and report performance to the legislature; verify accrediting organization standards and enforce the requirement that hospitals submit inspection proof; assess whether language access barriers limit use of the complaint system; review hospitals’ corrective plans for adverse health events and provide technical assistance to prevent recurrences; and make reported hospital data more accessible to the public.

DOH officials at the meeting acknowledged the issues and said pandemic‑era pauses, increased inspection scope and other workloads contributed to inspection delays. Ramiro Cantu, director of the Office of Health Systems Oversight, said the inspection cadence will take years to realign due to the way averages are computed and the reliance on third‑party accrediting schedules. The assistant secretary for the Health Systems Quality Assurance Division said the department welcomes JLARC’s recommendations and will work with JLARC and stakeholders to address them.

JLARC staff said they will present a proposed final report in July that will include agency responses.