WAC 246-330-155   Coordinated quality improvement program.  The purpose of this section is to ensure the establishment and on-going maintenance of a coordinated quality improvement program. The intent is to improve the quality of health care services provided to patients and to identify and prevent medical malpractice.

     An ambulatory surgical facility must:

     (1) Have a facility-wide approach to process design and performance measurement, assessment, and improving patient care services according to RCW 70.230.080 including, but not limited to:

     (a) A written performance improvement plan that is periodically evaluated;

     (b) Performance improvement activities that are interdisciplinary and include at least one member of the governing authority;

     (c) Prioritize performance improvement activities;

     (d) Implement and monitor actions taken to improve performance;

     (e) Education programs dealing with performance improvement, patient safety, medication errors, injury prevention; and

     (f) Review serious or unanticipated patient outcomes in a timely manner.

     (2) Systematically collect, measure and assess data on processes and outcomes related to patient care and organization functions;

     (3) Collect, measure and assess data including, but not limited to:

     (a) Operative, other invasive, and noninvasive procedures that place patients at risk;

     (b) Infection rates, pathogen distributions and antimicrobial susceptibility profiles;

     (c) Death;

     (d) Medication management or administration related to wrong medication, wrong dose, wrong time, near misses and any other medication errors and incidents;

     (e) Injuries, falls, restraint use, negative health outcomes and incidents injurious to patients in the ambulatory surgical facility;

     (f) Adverse events according to chapter 70.56 RCW;

     (g) Discrepancies or patterns between preoperative and postoperative (including pathologic) diagnosis, including pathologic review of specimens removed during surgical or invasive procedures;

     (h) Adverse drug reactions (as defined by the ambulatory surgical facility);

     (i) Confirmed transfusion reactions;

     (j) Patient grievances, needs, expectations, and satisfaction; and

     (k) Quality control and risk management activities.



[Statutory Authority: Chapter 70.230 RCW. 09-09-032, § 246-330-155, filed 4/7/09, effective 5/8/09.]