Acute care hospitals and psychiatric hospitals must report to the department within 48 hours certain serious adverse events categories as adopted by the National Quality Forum.
- Refer to WAC 246-320-146 (acute care hospitals), WAC 246-322-260 (psychiatric hospitals) and RCW 70.56.020 for specific regulatory language
- Adverse events list (PDF)
- Report an adverse event to the department
A medical facility (hospital, ambulatory surgery center, etc.) must report to the department when the hospital restricts the privileges of a practitioner based on professional misconduct, substandard practice or because of a mental or physical condition.
- Refer to RCW 70.41.210 and WAC 246-16-245 for the specific regulatory language
- The misconduct must amount to a violation of the Uniform Disciplinary Act (RCW 18.130)
- File a complaint to the department regarding a healthcare practitioner's termination or restriction
Reportable Operational or Maintenance Events
Acute care hospitals must report to the department within 48 hours certain serious events affecting the operation and maintenance of the facility.
- Refer to WAC 246-320-151 for specific regulatory language.
- Report an operational or maintenance event to the department through the Health Systems Quality Assurance complaint intake process. This ensures the information is documented and routed to the appropriate entities to respond.
Certain communicable diseases or conditions of public health importance, once discovered at a facility, must be reported to the department.
- Refer to WAC 246-320-176, 246-100 WAC, RCW 70.41.430, RCW 43.70.056 for specific rules and regulations
- Report a notifiable condition and see a list of notifiable conditions
- Notifiable conditions should be reported to your local health agency. In the event that your local health agency isn't available, report a notifiable condition to the department
Healthcare Associated Infections
Acute care hospitals must report monthly to the department certain data about healthcare associated infections (HAI) and on those at-risk for infection, using CDC's National Healthcare Safety Network (NHSN) protocols.
- Refer to RCW 43.70.056 and WAC 246-440-100 for specific rules and regulations
- Hospitals enroll in National Healthcare Safety Network (NHSN), a national HAI surveillance system, to report HAI data, which is used by the department's Healthcare Associated Infection Program to provide evidence-based information to reduce HAIs and inform the public
Other Administrative Matters to Report
Acute care hospitals must report any accreditation decision or any changes in accreditation status to the department within 30 calendar days.
- Refer to RCW 70.41.122 and WAC 246-320-111 for specific regulatory language
- Report these accreditation decisions in email to the facilities review team
Acute care hospitals must report that an accreditation survey has been completed within two business days following the completion of the survey.
- Refer to WAC 246-320-111 for specific regulatory language
Changes to Certain Policies
Acute care hospitals must submit to the department certain policies and report any changes or additions to these policies. They include policies regarding admission, nondiscrimination, reproductive health, end of life and charity care.
- Refer to WAC 246-320-141, RCW 70.170.060 and WAC 246-453-070 for specific regulatory language