Improving the Hospital Inspection Process


Impact Statement: 
Washington State Department of Health enhanced their ability to lower the risk of clients receiving substandard care in hospital settings. Using a Lean process, staff implemented a host of improvements to increase the rate of hospital inspections conducted within the state-mandated 18-month timeline to 100%, up from the baseline of 52%. The pre-inspection process time has been reduced from 63 days to 10 days, the post-inspection process for a reduced from greater than 200 days to 35 days, and the on-site inspection process improved by removing duplicative steps and reconfiguring the inspection teams. The agency is measuring progress toward the aim of 100% of inspections occurring within the required timeline.
The Washington State Department of Health is mandated by state law to inspect hospitals every 18 months and was not meeting these mandates. This noncompliance could increase the risk of clients receiving substandard care. The project aim was to increase the percentage of acute care hospital inspections within an 18-month timeline from 52% to 75% by December 2012 and to 100% by December 2013. The hospital inspection process has three phases: pre-inspection, on-site, and post-inspection. The Department of Health wanted to optimize existing resources, standardize the inspection process, and decrease the overall time it takes to conduct all three phases of a hospital inspection. As a result of this project, the Department of Health made improvements on all three processes: optimized existing resources, standardized the inspection process, and decreased the overall time it takes to conduct inspections. New office protocols for inspection preparation and wrap-up were developed. The pre-inspection preparation process was reduced from 63 days to 10 days, and the post-inspection process was reduced from more than 200 days to 35 days to close out a routine inspection. The Department of Health discovered overlapping and duplicate duties in the on-site inspection. In some cases, nurses and life/safety inspectors were performing the same tasks. The Department of Health was over-inspecting. Every hospital unit was inspected extensively despite similarities of the operations; all the nurses were looking at the same processes on every unit. The life/safety inspectors did not need the same on-site time to complete their inspection. As a result, the Department of Health now has more coherent and effectively sized teams.
Organization that conducted the QI initiative: 
Washington State Department of Health; 101 Israel Road SE; Tumwater, WA 98501

Ehri, D. Public Health Quality Improvement Exchange. Improving the Hospital Inspection Process. Fri, 11/03/2017 - 06:11. Available at Accessed April 14, 2024.

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Grace Gorenflo's picture
Submitted by Grace Gorenflo on

This is a phenomenal example several different QI methods and tools! Your value stream maps very clearly show the streamlined process that resulted from your efforts, and all of the visuals and tools included in the files you've provided are very helpful additions to further illustrate your work. Could you please comment on your experience with including hospital representatives in the effort -- e.g., any barriers to engaging them and how they were overcome, your sense of their perception of this effort, etc. Thanks!

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Submitted by DianaEhri on

The hospital staff we brought in had no problems engaging in the process. They participated on the 1st day. They were comfortable telling us what worked and didn't work for them. They came back on the last day for the report out. They appreciated the fact that we listened to them and addressed their concerns and modified our process based on those concerns. Where we couldn't modifiy the process -- we let them know why. All in all, it was a great experience.

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