WAC 246-330-115   Governance.  This section outlines the organizational guidance and oversight responsibilities of ambulatory surgical facility resources and staff to support safe patient care.

     An ambulatory surgical facility must have a governing authority that is responsible for determining, implementing, monitoring and revising policies and procedures covering the operation of the facility that includes:

     (1) Selecting and periodically evaluating a chief executive officer or administrator;

     (2) Appointing and periodically reviewing a medical staff;

     (3) Approving the medical staff bylaws;

     (4) Reporting practitioners according to RCW 70.230.120;

     (5) Informing patients of any unanticipated outcomes according to RCW 70.230.150;

     (6) Establishing and approving a coordinated quality performance improvement plan according to RCW 70.230.080;

     (7) Establishing and approving a facility safety and emergency training program according to RCW 70.230.060;

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

     (9) Providing a patient and family grievance process including a time frame for resolving each grievance according to RCW 70.230.080 (1)(d);

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

     (11) Defining who can authenticate written or electronic orders for all drugs, intravenous solutions, blood, and medical treatments that are consistent with professional licensing laws.



[Statutory Authority: Chapter 70.230 RCW. 09-09-032, § 246-330-115, filed 4/7/09, effective 5/8/09.]