Statement from Assistant Secretary Carla Reyes on Western State Hospital accreditation status

Release Date: 
Aug 28 2016
DSHS Office of Communications
Kathy Spears
(360) 485-8233

OLYMPIA— Western State Hospital and the Department of Social and Health Services places first priority on ensuring the hospital is providing safe, quality care and in meeting the terms and conditions of the Systems Improvement Agreement (SIA). This is an agreement made with the Centers for Medicare and Medicaid Services (CMS), which provides us the time we need to fix many of the systemic operational problems that have kept WSH out of compliance with their standards of care. 

In June, the Department determined to discontinue its relationship with The Joint Commission (TJC). This followed consultation with CMS, the independent expert consultant overseeing our progress with the SIA, legal counsel and the Governor’s Office.
TJC accreditation is not required by CMS. If a hospital chooses to pursue and achieves TJC accreditation, the hospital is given “deemed” status—essentially identifying that it has met or exceeded requirements related to CMS hospital Conditions of Participation. TJC wanted to conduct its scheduled triennial survey in June 2016; however, at that time WSH had already been determined by CMS to be out of compliance with CMS Conditions of Participation and no longer to be afforded the “deemed” status that successful TJC accreditation offers.  

A survey by TJC at this time could not return the hospital’s deemed status, and we did not believe we could meet the TJC accreditation standards if we were already determined to not be meeting CMS’ Conditions of Participation. Given this reality, it did not make sense to go through another external survey since we are now working directly with CMS. We did ask TJC if they could delay their survey until after the work with CMS was completed, but they were not willing to do so and we chose to withdraw from the accreditation process.

WSH had been working directly with CMS and the Department of Health for months on numerous hospital surveys and re-surveys. An additional survey by TJC would not have provided an opportunity for the hospital to regain compliance with the Conditions of Participation. That process could only occur as outlined in the SIA agreement with CMS.

We don’t believe that lack of accreditation will jeopardize the care, safety and security our patients.  However, they will be impacted if we continue to not meet the CMS conditions. For this reason, we are focused on meeting the terms of our SIA.

It is my understanding that hospital administration prepared notification to staff regarding this decision; however, it appears that during the notifications regarding the SIA, the information regarding TJC accreditation was not distributed. CEO Strange informs me that there were discussions about the change during supervisors meetings and leadership team meetings. Further, the website and hiring information was not updated with this information. This was an unintentional oversight which the hospital has moved immediately to correct.

Under the terms of our SIA with CMS, there is oversight by a CMS approved Independent Expert Consultant; required regular reporting directly to CMS; and a required CMS return survey prior to the end of the SIA term to ensure the hospital has been returned to meeting the CMS required Conditions of Participation.

Once we meet these requirements at WSH we can pursue accreditation once again.

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The Behavioral Health Administration provides inpatient and outpatient psychiatric treatment, recovery support along with prevention and intervention programs for people with mental health needs and substance abuse concerns. It operates three state psychiatric hospitals that deliver high-quality services to adults and children with complex needs. BHA’s team of 2,804 staff ensures that nearly 150,000 people receive needed services each year on a $910 million annual budget. 


DSHS does not discriminate and provides equal access to its programs and services for all persons without regard to race, color, gender, religion, creed, marital status, national origin, sexual orientation, age, veteran’s status or the presence of any physical, sensory or mental disability.