DOH Begins Review of Certificate of Need Tertiary Health Services

January 14, 2015

To:  Hospital CEOs and Administrators, Government Affairs, CN Task Force Members

From:  Zosia Stanley, Policy Director, Access

            Claudia Sanders, SVP, Policy Development

Staff Contact:  Zosia Stanley, or (206) 216-2511


The Washington State Department of Health (the Department) Certificate of Need program has announced it is moving forward with review of tertiary health services that are subject to Certificate of Need. The Department will determine whether any changes are necessary to the tertiary health services list. Changes could include additions to or deletions from the list.

We want to make sure you are aware this process has started so you can participate as appropriate in the public comment period, the first phase of which is January 1, 2015 to February 28, 2015.


The Department’s work on the list of services has the potential to markedly impact hospital business planning and service line development. Hospitals that provide tertiary type care may want to be engaged with the Department during the review period. WSHA will actively monitor the review process, but as there may not be consensus among members, hospitals should plan to engage directly with the Department. We recognize there may not be consensus among members.


  • Review the notice of tertiary health services review available on the Department’s website.
  • Review the list of services currently categorized as tertiary and subject to Certificate of Need review, included below.
  • Note the proposed timeline and phases of review. During Phase 1, running from January 1, 2015 to February 28, 2015, the Department is accepting comments on the appropriateness of the current list of tertiary services.  
  • Determine if your hospital wishes to propose additions or deletions from the tertiary health services list and if so, provide comments to the Department before February 28, 2015.
  • Contact the Department directly with questions, comments, or concerns. The staff person on this project is Kyle Karinen, Office of Legal Services. Kyle asked that WSHA share his direct contact information: (360) 236-4810 or
  • Let us know if you have a staff person who will be engaged in this process, so we can communicate with them directly in the future. Send name and contacts to Zosia Stanley at


Under state law, any new tertiary health services offered in or through a health care facility that has not been previously offered on a regular basis or within the last twelve months is subject to Certificate of Need review.[1] However, not all services or service lines are considered “tertiary health services” and subject to review.

The Department determines which services qualify for tertiary health services review based on seven criteria:

  • Whether the service is dependent on the skills and coordination of specialties and subspecialties including, but not limited to, physicians, nurses, therapists, social workers.
  • Whether the service requires immediate access to an acute care hospital.
  • Whether the service is characterized by relatively few providers.
  • Whether the service is broader than a procedure.
  • Whether the service has a low use rate.
  • Whether consensus supports or published research shows that sufficient volume is required to impact structure, process, and outcomes of care.
  • Whether the service carries a significant risk or consequence.

Based on these criteria, the following services are currently considered “tertiary health services” and subject to Certificate of Need:

  • Specialty burn services
  • Intermediate care nursery and/or obstetric services Level II
  • Neonatal intensive care nursery and/or obstetric services Level III
  • Transplantation of specific solid organs
  • Open heart surgery and/or elective therapeutic cardiac catheterization, including percutaneous coronary interventions generally and elective percutaneous coronary angioplasty (PTCA), specifically
  • Inpatient physical rehabilitation services Level I
  • Specialized inpatient pediatric services.

According to rule, the Department is required to convene a technical work group at least every three years to review the criteria listed above to determine whether the criteria appropriately define a tertiary service and propose changes to the list of tertiary services.[2] However, this is the first time the Department has engaged in this review. The Department has indicated it intends to institute a regular review of tertiary services in accordance with the three year time period.

The Department has laid out the following timeline for review:

  • Phase 1: January 1, 2015 – February 28, 2015. A two-month period for people to propose changes to the current list of tertiary services. All proposed changes must address whether the service meets or partially meets the criteria for evaluation (listed above). At the end of this phase, the Department issues a report of proposed changes.
  • Phase 2: March 16, 2015 – April 15, 2015. A 30-day comment period for people to comment on the report of proposed changes.
  • Phase 3: April 16, 2015 – June 15, 2015.  The Department will assess comments or proposals and decide if any changes to the current list of tertiary services are necessary.

If the review results in a determination that the current list of tertiary services needs to be changed, the Department will engage in a rule-making process.

If your hospital provides comments during the review process, it is important that comments specifically reference the tertiary health services criteria in WAC 246-310-035 and listed above.  The Department has indicated these are the standards it will look to in making determinations.

Finally, the Department has shared with WSHA its intent to engage in a transparent process that allows stakeholders to engage and offer substantive input.


Please do not hesitate to contact WSHA or the Department with your questions. Zosia Stanley, Policy Director, Access, can be reached at or (206) 216-2511. Kyle Karinen with the Department can be reached at or (360) 236-4810. 



[1] WAC 246-310-020(1)(d).

[2]WAC 246-310-035(4).


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