WAC 246-324-040   Governing body and administration.  The governing body shall:

     (1) Adopt written policies concerning the purposes, operation and maintenance of the hospital, and the safety, care and treatment of patients;

     (2) Provide staff, facilities, equipment, supplies and services to meet the needs of patients within the purposes of the hospital;

     (3) Establish and maintain a current written organizational plan delineating positions, responsibilities, authorities, and relationships of positions within the hospital;

     (4) Appoint an administrator responsible for implementing the policies adopted by the governing body;

     (5) Appoint a physician as medical director responsible for directing and supervising medical treatment and patient care twenty-four hours per day;

     (6) Maintain an organized professional staff accountable to the governing body;

     (7) Appoint and periodically reappoint the professional staff;

     (8) Require and approve professional staff bylaws and rules concerning, at a minimum:

     (a) Organization of the professional staff;

     (b) Delineation of privileges;

     (c) Requirements for membership;

     (d) Specific mechanisms for appointing and reappointing members;

     (e) Granting, renewing and revising clinical privileges;

     (f) Self-government;

     (g) Required functions;

     (h) Accountability to the governing body; and

     (i) Mechanisms to monitor and evaluate quality of care and clinical performance; and

     (9) Require that each person admitted to the hospital is under the care of a professional staff member with clinical privileges.



[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. 95-22-013, § 246-324-040, filed 10/20/95, effective 11/20/95.]