DOH hospital oversight — JLARC finds 72% of inspections late, mandatory adverse-event reviews not done since 2011

A JLARC performance audit approved July 16, 2025 found that the Washington State Department of Health has not met its statutory hospital inspection schedule since 2015 — with 72% of acute-care hospital inspections late as of December 2024, nearly half overdue by six months or more — and has not reviewed mandatory adverse health event correction plans submitted by hospitals since at least 2011.

What happened

In 2022, the Legislature directed JLARC to evaluate DOH’s oversight of hospital inspections, patient complaints, and data reporting. JLARC published a preliminary report in May 2025 and approved the final report (25-06) at its July 16, 2025 meeting.

The audit covered 93 acute-care hospitals in Washington state. Key findings:

Inspection backlog. State law requires DOH to inspect each acute-care hospital “on average, at least every 18 months.” DOH has not met this requirement since 2015. As of December 2024, only 28% of the 93 acute-care hospitals were inspected on time; 72% were late, with nearly half overdue by at least six months. Some hospitals were overdue by six or more years. The law does not specify a maximum timeframe or set a mechanism by which DOH must explain or remedy missed inspections.

Third-party inspection equivalency not verified. DOH is permitted to accept inspections by accrediting organizations (such as The Joint Commission) as satisfying state requirements, but only if DOH has verified that the organization’s standards are “substantially equivalent” to state standards and receives documentary evidence that the inspection was completed. DOH has not verified any accrediting organization’s standards, and does not receive documentation from all hospitals that use these organizations. As a result, DOH does not know whether the hospitals using third-party inspectors are actually meeting state standards.

Adverse health event correction plans not reviewed. State law requires hospitals to report adverse health events (avoidable medical errors) to DOH along with a correction plan to prevent recurrence. State law requires DOH to review these plans. DOH has not reviewed or analyzed these reports since at least 2011, despite an 84% increase in adverse event reports since 2016. Correction plans submitted by hospitals after serious adverse events sit unreviewed. There is no documented enforcement mechanism for this failure.

Data accessibility. DOH publishes hospital data on its website. JLARC found other states make similar information more accessible to the public, and recommended DOH improve public data accessibility.

JLARC issued six recommendations. DOH agreed to all recommendations and committed to presenting a strategic management plan and progress report at JLARC’s July 2026 meeting. One-time funding for a DOH staff position to address inspection backlog was provided by the Legislature; the position was filled February 2025 and funding expired June 2025 — the same month the audit period was current.

What the primary source says

The JLARC 25-06 Final Report states: “The Department of Health (DOH) does not complete inspections on time, ensure third-party inspections meet state standards, or review medical error reports. This limits its ability to ensure patient safety.”

The executive summary PDF states directly: “DOH does not review hospitals’ reports of adverse health events as required by law” and “72% of hospital inspections were late, with nearly half overdue by 6 months or more.”

The preliminary briefing at the May 14, 2025 JLARC meeting directed DOH to create a strategic management plan, with DOH agreeing to present progress at the July 2026 meeting.

Status

Audit finding as of July 16, 2025. DOH has agreed to JLARC’s six recommendations. Progress report due at JLARC’s July 2026 meeting. No independent mechanism exists to enforce the statutory inspection schedule between JLARC oversight cycles.

Why it’s in the registry

This case documents a decade-long pattern of statutory noncompliance at a state agency responsible for patient safety in acute-care hospitals. The adverse-event correction plan failure is particularly striking: the law has required DOH to review these plans since at least 2011, hospitals have been submitting them, and DOH has not reviewed a single one in over fourteen years while adverse event reports increased 84%. This is not a resource gap — it is a structural failure in regulatory design that JLARC has now formally documented.

Reform implication

The inspection and adverse-event failures at DOH are structurally identical to other cases in this registry: a statutory mandate with no enforcement mechanism and no independent monitor to catch noncompliance until a legislative audit surfaces it. The Legislature directed DOH to inspect hospitals and review correction plans; it did not create a mechanism to compel compliance or fund the work sustainably. One-time staffing fixes do not address a ten-year backlog. See [reform: regulatory_capacity] and [reform: patient_safety_oversight].