WAC 246-320-136   Leadership.  This section describes leadership's role in assuring care is provided consistently throughout the hospital and according to patient and community needs.

     The hospital leaders must:

     (1) Appoint or assign a nurse at the executive level to:

     (a) Direct the nursing services; and

     (b) Approve patient care policies, nursing practices and procedures;

     (2) Establish hospital-wide patient care services appropriate for the patients served and available resources which includes:

     (a) Approving department specific scope of services;

     (b) Integrating and coordinating patient care services;

     (c) Standardizing the uniform performance of patient care processes;

     (d) Establishing a hospital-approved procedure for double checking certain drugs, biologicals, and agents by appropriately licensed personnel; and

     (e) Ensuring immediate access and appropriate dosages for emergency drugs;

     (3) Adopt and implement policies and procedures which define standards of care for each specialty service;

     (4) Provide practitioner oversight for each specialty service with experience in those specialized services. Specialized services include, but are not limited to:

     (a) Surgery;

     (b) Anesthesia;

     (c) Obstetrics;

     (d) Neonatal;

     (e) Pediatrics;

     (f) Critical or intensive care;

     (g) Alcohol or substance abuse;

     (h) Psychiatric;

     (i) Emergency; and

     (j) Dialysis;

     (5) Provide all patients access to safe and appropriate care;

     (6) Adopt and implement policies and procedures addressing patient care and nursing practices;

     (7) Require that individuals conducting business in the hospital comply with hospital policies and procedures;

     (8) Establish and implement processes for:

     (a) Gathering, assessing and acting on information regarding patient and family satisfaction with the services provided;

     (b) Posting the complaint hotline notice according to RCW 70.41.330; and

     (c) Providing patients written billing statements according to RCW 70.41.400;

     (9) Plan, promote, and conduct organization-wide performance-improvement activities according to WAC 246-320-171;

     (10) Adopt and implement policies and procedures concerning abandoned newborn babies and hospitals as a safe haven according to RCW 13.34.360;

     (11) Adopt and implement policies and procedures to require that suspected abuse, assault, sexual assault or other possible crime is reported within forty-eight hours to local police or the appropriate law enforcement agency according to RCW 26.44.030.



[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. 09-07-050, § 246-320-136, filed 3/11/09, effective 4/11/09.]