WAC 246-320-131   Governance.  This section provides organizational guidance and oversight responsibilities of hospital resources and staff to support safe patient care.

     For the purposes of this section "practitioner" means pharmacists as defined in chapter 18.64 RCW; advanced registered nurse practitioners as defined in chapter 18.79 RCW; dentists as defined in chapter 18.32 RCW; naturopaths as defined in chapter 18.36A RCW; optometrists as defined in chapter 18.53 RCW; osteopathic physicians and surgeons as defined in chapter 18.57 RCW; osteopathic physicians' assistants as defined in chapter 18.57A RCW; physicians as defined in chapter 18.71 RCW; physician assistants as defined in chapter 18.71A RCW; podiatric physicians and surgeons as defined in chapter 18.22 RCW; and psychologists as defined in chapter 18.83 RCW.

     The governing authority must:

     (1) Establish and review governing authority policies including requirements for:

     (a) Reporting practitioners according to RCW 70.41.210;

     (b) Informing patients of any unanticipated outcomes according to RCW 70.41.380;

     (c) Establishing and approving a performance improvement plan;

     (d) Providing organizational management and planning;

     (e) Reporting adverse events and conducting root cause analyses according to RCW 70.56.020;

     (f) Providing a patient and family grievance process including a time frame for resolving each grievance;

     (g) Defining who can give and receive patient care orders that are consistent with professional licensing laws; and

     (h) Providing communication and conflict resolution between the medical staff and the governing authority;

     (2) Establish a process for selecting and periodically evaluating a chief executive officer or administrator;

     (3) Appoint and approve a medical staff;

     (4) Require written or electronic orders, authenticated by a legally authorized practitioner, for all drugs, intravenous solutions, blood, medical treatments, and nutrition; and

     (5) Approve and periodically review bylaws, rules, and regulations adopted by the medical staff before they become effective.



[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. 09-07-050, § 246-320-131, filed 3/11/09, effective 4/11/09.]