What are Washington DOH and DNV inspectors focusing on?

June 15, 2023

Now that the Washington State Department of Health (DOH) and DNV have resumed their normal inspection schedules, Washington State hospitals are lending some insight into the areas these accrediting organizations are focusing on most. These areas include:

  • Restraints and suicide monitoring
  • The grievance process
  • How hospitals contract with (and manage) vendors
  • Formaldehyde monitoring and storage
  • Procedure room smoke evacuation systems (new legislation will go into effect 1/1/24 except for CAHs, for whom it will then go into effect on 1/1/25).
  • What hospitals are doing to keep SSI and HAI rates down
  • Med staff services – Data that is being used for OPPE and provider monitoring
  • QAPI process and what quality improvement plans are in place for the institution
  • Swing bed requirements
  • Medication management
  • Outdates
  • Hand hygiene
  • Proper cleaning of high use equipment between patient use (ex. Blood pressure machines, glucometers, SaO2 probes)
  • Nurse staffing committees
  • MDRO policy and/or screening of patients
  • Restraints/seclusion (physical and chemical)
  • ICP
  • Patient rights
  • All environment of care plans (they are very focused on these, and how hospitals communicate those plans to the entire organization)
  • Electrical panel safety
  • Oxygen storage
  • Fire suppression system
  • Fire extinguishers
  • Electrical safety – Open junction boxes
  • Hazardous areas – Clean supply storage
  • Fire/smoke doors

If you would like assistance preparing for your next DOH, CMS or DNV inspection, Washington Hospital Services offers pre-survey inspections in the following focus areas: clinical quality, environment of care and infection prevention.

For more information, or to schedule a pre-survey inspection visit, please contact WHS Assistant Director, Quality & Clinical Services Rich Boucher at richb@wsha.org or 206-216-2504. (Rich Boucher)



Contact Us

Washington State Hospital Association
999 Third Avenue
Suite 1400
Seattle, WA 98104

Map / Directions

206.281.7211 phone
206.283.6122 fax


Staff List